FRCA Notes

Arthroplasty

Neither elective hip nor elective knee arthroplasty has featured as a Final FRCA SAQ/CRQ.

The curriculum asks for knowledge of 'the difference in anaesthetic and surgical complexity between primary and secondary lower limb arthroplasty' and 'the principles of perioperative anaesthetic care for pelvic bone and joint surgery'

Resources

  • Patients undergoing primary elective arthroplasty are most often doing so for osteoarthritis
  • They may, although not always, be younger and less comorbid

Secondary (revision)

  • Patients undergoing secondary arthroplasty tend to be more complex, on account of:
    • Being older
    • Having a greater number of comorbidities
    • Having suffered a complication requiring a revision e.g. fracture, recurrent dislocation, infection or prosthesis failure

  • Revision arthroplasties therefore tend to be:
    • Longer, either as stand-alone operations or as two-stage revisions
    • Associated with greater blood loss

Anaesthesia

  • Neuraxial techniques are generally preferred
  • Options include spinal anaesthesia, CSE or epidural techniques
    • Spinal anaesthesia is recommended by multiple guidelines

  • ± procedural sedation
    • Usually propofol TCI
    • Patient-controlled procedural sedation is associated with fewer sedation-associated adverse events than anaesthetist-led TCI (BJA, 2021)

  • General anaesthesia, combined with regional analgesic techniques, for those in whom neuraxial techniques are contra-indicated or have failed

Analgesia

  • ± consider 100mcg morphine intrathecally if spinal anaesthetic used
  • Single-shot fascia iliaca block or local wound LA infiltration

  • Simple analgesia (paracetamol + NSAID if not contraindicated) either pre- or intra-operatively
  • Single dose of intra-operative dexamethasone for analgesic properties
  • Consider intra-operative adjuncts such as:
    • Ketamine 0.1-0.3mg/kg IV
    • Magnesium 50mg/kg IV over 30mins

  • Post-operatively:
    • Regular paracetamol
    • Consider NSAID with PPI cover
    • Consider nefopam in those not able to have NSAIDs
    • Reserve opioids for rescue analgesia (consider oxycodone rather than morphine)

  • Compared with THR, is associated with greater degrees of post-operative pain on account of:
    • Extensive osteotomy
    • Splitting of the quadriceps muscle
  • Conversely, there is less blood loss owing to relevant anatomy and use of tourniquets

Anaesthesia

  • Neuraxial techniques are generally preferred
  • Options include spinal anaesthesia, CSE or epidural techniques
    • Spinal anaesthesia is recommended by multiple guidelines
  • ± propofol TCI sedation

  • General anaesthesia, combined with regional analgesic techniques, for those in whom neuraxial techniques are contra-indicated or have failed

Analgesia

  • Simple analgesia (paracetamol + NSAID if not contraindicated) either pre- or intra-operatively
  • Consider single dose of pre-operative, long-acting opioid

  • Single dose of intra-operative dexamethasone for analgesic properties (higher doses not superior to lower doses)
  • Consider intra-operative adjuncts such as:
    • Intra-articular NSAID
    • Ketamine 0.1-0.3mg/kg IV (although conflicting evidence base)
    • Magnesium 50mg/kg IV over 30mins

  • Peri-operative regional anaesthetic options
    • Adductor canal block
    • IPACK block
    • Local anaesthetic wound infiltration

  • Post-operatively:
    • Regular paracetamol
    • Consider NSAID with PPI cover
    • Consider nefopam in those not able to have NSAIDs
    • Reserve opioids for rescue analgesia (consider oxycodone rather than morphine)
      • Transdermal fentanyl may be as efficacious as fentanyl PCA, with the benefit for improved mobility but a slower onset time
    • Non-pharmacological methods such as cryocuff, which may provide analgesia, physical support and increase ROM

Perioperative care of the patient undergoing elective arthroplasty


  • A full history and examination as standard
  • Adequaate assessment of functional reserve may be difficult owing to:
    • Limitations to function being from pain rather than poor cardiorespiratory reserve
    • Routine pre-operative investigations typically examining the patient at rest and therefore information from these may be limited

Optimisation

  • Address common comorbidities such as anaemia, hypertension and diabetes as standard
  • Use of local ERAS programmes is associated with earlier discharge, increased patient satisfaction, reduced morbidity and potentially reduced mortality
  • 'Joint school' is a form of patient education which can reduce anxiety, though has not been proved to reduce length of stay, post-operative pain or increase post-operative function

Secondary (revision)

  • Patients are older and more comorbid, so require appropriate optimisation
  • Blood loss may be significant; cross-match blood rather than G&S
  • Revision surgery takes longer and single-shot neuraxial anaesthetic techniques may not provide sufficient duration of action
  • Tend to have increased post-operative pain
  • Therefore require appropriate planning for intra-operative techniques and suitable post-operative location e.g. HDU

Choice of technique

  • As ever, anaesthetic techniques will need to be tailored to the individual patient and surgery
  • There is no difference in long-term morbidity or mortality between RA and GA for elective lower limb joint surgery
  • However, regional/neuraxial techniques are associated with reductions in
    • Opioid consumption
    • PONV
    • Post-operative pain
    • Time to mobilisation
    • Length of stay (for TKR)

  • See sections above for THR- and TKR-specific anaesthetic techniques

Monitoring

  • AAGBI as standard
  • May require intra-arterial monitoring if significant cardiorespiratory disease, or secondary arthroplasty
  • Multiple wide-bore cannulae in secondary arthroplasty, given bleeding risk
  • ± CVC
  • Temperature monitoring, as patients at higher risk of hypothermia especially if longer operative times

Positioning

  • Meticulous patient positioning is essential, as the patient population are typically at higher risk
  • Especially so for revision surgery, where operative times are longer
  • Positioning may limit airway access, which might influence choice of airway device

Care bundle

  • Antibiotic prophylaxis as per local guidelines
    • Revision surgery may have specific requirements, tailored to microbiology advice
  • Temperature monitoring and management
  • Intra-operative VTE prophylaxis with mechanical devices

  • Avoid urinary catheterisation
  • Avoid indwelling drains

Haemorrhage

  • Pre-operative cross-match
  • Consider use of cell salvage, especially in revision arthroplasty
  • Give TXA 15mg/kg (pre-operative PO TXA may be as effective as intra-operative IV TXA)
  • Use limb tourniquet in TKR
  • Good communication with the surgical team re: ongoing blood loss

  • HDU care may be indicated, especially for revision arthroplasty owing to:
    • Longer operative time
    • More heavily comorbid patients
    • Greater degree of blood loss
    • Use of techniques not amenable to ward beds e.g. epidural analgesia

  • Analgesia is as per sections above relating to THR and TKR