Anesthesia & Clinical Research

Anesthesia & Clinical Research
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ISSN: 2155-6148

Mini Review - (2022)Volume 13, Issue 8

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Modern Analgesic Techniques for Hip and Knee Arthroplasty: An Update from Daily Practice to Evidence-Based Medicine

Denisa Madalina Anastase* and Simona Cionac Florescu
 
*Correspondence: Denisa Madalina Anastase, Department of Anesthesiology, Clinical Hospital of Orthopedy Foisor, Bucharest, Romania, Email:

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Abstract

Total arthroplasty of the Hip (THA) or Knee (TKA) are common surgery today. The treatment of postoperative pain continues to be a challenge because it influences the surgical outcome, early mobilization, shortened Length of Stay (LOS), and discharge. Among the changes in practice in the last decades, we have seen a global shift toward valuebased care focusing on patient optimization prior to surgery in order to increase the quality of life and improve the outcomes.

Keywords

Rigid bronchoscopy; Respiratory distress; Papilloma; Cardiopulmonary resuscitation

Introduction

At the same time, there is a major change in the healthcare policy makers related to the healthcare environment. Medicare studies show that one-third of patients who undergo a TKA are less than 65 years of age and the predictions are that by 2030 younger patients would represent the majority of patients with this type of surgery [1]. Studies of differences in demographics, comorbidity, and episodes of care can be the foundation for removing THA and TKA from the inpatient-only list while recommending outpatient surgery for suitable patients [2]. Once more this was possible because in recent years a steady decrease in duration in hospital LOS has been observed [3,4]. When asked what the main predictors of LOS hospital after THA, the Cleveland Group studying a cohort of 5281 patients who underwent THA from 2016 to 2019 concluded that procedurerelated risk factors remain the main drivers of predicting LOS more than one day [5,6].

The concept of fast-track surgery represents a coordinated perioperative approach with the aim of reducing operative stress and increasing postoperative recovery in different types of surgeries, including orthopedic surgery on a procedure-specific basis [7]. Since 2008, Husted has shown the possibility of discharge in less than 2 days in younger patients by applying the fast-track protocol for THA and TKA [8]. Later, in another study, he showed that almost all unselected THA and TKA patients can be discharged within 3 days postoperatively. Reducing this time interval to 1-2 days could be achieved by improving perioperative analgesia (multimodal, opioid-free analgesia) and function of the quadriceps muscles as well as solving possible logistical and organizational problems related to early discharge [9].

Therefore, according to White, et al. the anesthetist plays a key role in the fast-track surgery and the perioperative period by choosing preoperative medication, anesthetic and analgesic techniques, and drugs to decrease side effects [10]. The analgesic role of dexamethasone is known and there is still a debate related to its intravenous or perineural administration.

Literature Review

Chan, et al. study shows that a preoperative administration of 16 mg I.V. before knee replacement surgery leads to a decrease in postoperative pain and opioid consumption, an increase in quadriceps muscle strength as well as better mobilization and quality improvement of postoperative recovery [11].

The most recent review on pain management after TKA analyzes 151 systematic reviews, of which 106 met the prospect criteria. The conclusion is that multimodal analgesia is essential, including regional analgesia techniques like single shot adductor canal block and peri-articular local infiltration together with a single intra-operative dose of intravenous dexamethasone. Also, paracetamol and nonsteroidal anti-inflammatory or cyclo-oxygenase- 2-specific inhibitors are recommended for the postoperative period with opioids reserved as rescue analgesics. If regional analgesia techniques are not possible, a dose of intrathecal morphine 100 μg is added [12].

Regarding the perineural administration of dexamethasone in TKA, the study by Ortiz, et al. on 639 patients shows that peripheral nerve blocks with perineural dexamethasone improve postoperative analgesia for TKA. Dexamethasone as adjuvant to Adductor Canal Block (ACB) adds new possibilities to improve analgesia for TKA, and should be considered as an alternative to Femoral Nerve Block (FNB) [13].

However, one of the challenges of postoperative analgesia in TKA remains the increased incidence of severe postoperative pain between 10% and 36%, which requires continuous improvement of the analgesia techniques used [14]. In the study of Rodriguez-Patarroyo, et al. evidence supports the role of Regional Anesthesia (RA) to improve analgesic management and decrease opioid use [6]. To avoid motor impact and allow early mobilization, there is a shift in regional analgesia techniques, from the center to the periphery, to target sensitive nerve branches.

Chronologically, the same review divides regional analgesia techniques into classic techniques such as FNB, Sciatic Nerve Block (SNB), and ACB and new techniques, such as Infiltration between the Popliteal Artery and Capsule of Knee block (IPACK), Local Anesthetics Infiltration (LAI), and genicular nerve block.

FNB is still widely used, either as a single shot or using a catheter for continuous analgesia, having the advantage of not producing urinary retention, unlike epidural analgesia [15]. The main concern related to the use of FNB is related to the decrease in the strength of the quadriceps muscle, the increase in recovery time, and the risk of falling compared to ACB [16]. Nowadays, ultrasound-guided SNB is frequently used, but it is more of an adjunct than an absolute analgesic resource for knee surgery [17]. There are certain factors that predispose to a higher probability of postoperative SNB requirements: younger patients, lower BMI, depression, shorter operations using peripheral blocks or infiltration as an anesthetics technique [6].

Unlike FNB, ACB achieves more sensorial than motor block. Nowadays, ultrasound is commonly used to identify the adductor canal. ACB’s main advantage over previous techniques is its low impact on muscular strength. Many studies show that ACB has less effect on quadriceps strength compared to FNB. In addition, this block is associated with earlier mobilization and recovery, and pain scores were equivalent to FNB [18].

IPACK developed by Sinha in 2012 controls posterior knee pain after TKA with minimal impact on mobilization, without incidence of foot drop [19]. However, other authors report a low incidence of foot drop after IPACK, which may be due to the spread of the LA to the tibial and peroneal nerves [20]. IPACK block could be used in combination with FNB6, LAI, or ACB [21,22].

Regarding LAI, there is no consensus regarding the best use of LAI, often surgeons perform this technique using either plain Local Anesthetic (LA) or a combination of analgesic cocktail medications. Generally, it comprehends a high volume (150-170 mL) of a mixture of 0.2% ropivacaine or 0.125% levobupivacaine plus ketorolac and epinephrine [23]. The main concern related to the use of LAI refers to the dose and injected volume of LA and added adrenaline; therefore it is mandatory to administer it in safe conditions, having the LAST protocol available [24]. Genicular nerve block uses Radio Frequency Ablation (RFA) of the knee joint nerves [25]. This method is widely used in other areas, with no risk of toxicity (not LA use), but there is limited evidence for pain management after TKA, this technique is used especially for postoperative chronic pain management after TKA [26]. At the same time, efforts were made to improve LAs performance, in order to have new LAs with a longer duration of action than the previous ones. One of these LAs is liposomal bupivacaine. Current evidence, particularly for TKA, does not support its routine use over standard LA’s, both in peripheral nerve blocks and LAI techniques [27].

LAI has been studied in relation to both TKA and THA. Morrin's publication comprising 11 randomized trials in the field of THA and TKA reports comparisons between systemic analgesia and epidural or peripheral anesthesia. All of these showed positive results for LAI. In addition, LAI is safe, costeffective, and does not require special technical skills, unlike epidural and peripheral regional anesthesia [28]. Various nerve blocks with LA agents have been used to reduce pain after hip fracture and subsequent surgery. One of these is Fascia Iliaca Compartment Block (FICB) which should be part of a multimodal analgesic plan in the context of the management of hip fracture patients. In a recent review Verbeek, et al. discusses the perioperative effects of the FICB in hip fracture patients. Single-shot FICB provides about 8 h of analgesia when bupivacaine is used, with neuropathies and vascular injuries almost unlikely. Continuous FICB prolonged titratable analgesia, reduces opioid consumption, improves patient satisfaction, and leads to faster hospital discharge [29].

The Cochrane publication on peripheral nerve blocks for hip fractures focuses on the use of peripheral nerve blocks as both preoperative and postoperative analgesia or as an adjunct to general anesthesia for hip fracture surgery. High-quality evidence concludes that regional block reduces pain on movement within 30 minutes of performing the block. At the same time, moderate-quality evidence shows a reduced risk of pneumonia, shortened time to the first mobilization, and cost reduction of the analgesic regimen (single shot blocks) [30].

Discussion

The evidence-based international expert consensus panel recommends the use of PNB in THA and TKA for improved outcomes unless contraindications exclude their use. The level of evidence is moderate and the recommendation is strong [31]. Postoperative anesthesia and analgesia, particularly in TKA, can have an effect on long-term outcomes. Bugada's study shows that continuous regional analgesia can provide a benefit up to one month postoperatively, with no influence on pain at 6 months. However, there are patients predisposed to develop persistent postsurgical pain, namely patients with higher expectations from the surgery, increased basal inflammation, and a history of depression or anxiety [32].

Diversification of postoperative pain management comprises advancement in this field, increasing interest in new analgesic techniques to improve the outcomes of patients and their satisfaction. One of these is cryoanalgesia, which is variable and still an undiscovered field. Also called cryoneurolysis, it is a method of temporarily blocking nerves through very low temperatures. The duration of the block is unpredictable due to the factors involved (temperature, exposure time, and diameter of the nerve), but is usually counted in weeks or months. There is little clinical evidence about the use of cryoanalgesia in TKA. Although cryoanalgesia does not represent systemic toxicity, the risk of complete sensory and motor blockade, together with the uncertain time of its effect, may limit its use [6].

Another new technique of non-pharmacological analgesia is virtual reality, which works at the affective emotional level, cognitive and attentional processes based on emotion on the body. This technique starts from Ramachandran's study that used Mirror Therapy (MT) for phantom limb pain. The mechanism of action would be that MT confused the brain through inappropriate sensory inputs from the amputated arm. Thus, it caused the brain to choose visual information instead of the sensation of the amputated body [33]. Another study by Koo, et al. shows us that the technique of Enhanced Reality Showing can determine long-lasting analgesia after knee prosthesis, and could form the basis of future studies on the effects over time of this technique, which is safe, simple to perform, and without side effects [34].

Conclusion

In conclusion, in accordance with the global shift towards valuebased care in patients scheduled for TKA and THA, it is essential to choose a fast-track surgery technique and an adequate anaesthetic-analgesic management. This objective is not only providing adequate analgesia, but also reducing the LOS, improving recovery, and outcomes, and decreasing costs. Each of these new analgetic techniques has its adepts and the choice of one or another belongs not only to the anaestheticsurgical team according to the surgical technique but also to the practice location resources and has a single aim: a better prognosis for the patient [35].

References

Author Info

Denisa Madalina Anastase* and Simona Cionac Florescu
 
Department of Anesthesiology, Clinical Hospital of Orthopedy Foisor, Bucharest, Romania
 

Citation: Anastase DM, Florescu SC (2022) Modern Analgesic Techniques for Hip and Knee Arthroplasty: An Update from Daily Practice to Evidence-Based Medicine.J Anesth Clin Res. 13:1076.

Received: 04-Jul-2022, Manuscript No. JACR-22-18521; Editor assigned: 06-Jul-2022, Pre QC No. JACR-22-18521 (PQ); Reviewed: 21-Jul-2022, QC No. JACR-22-18521; Revised: 28-Jul-2022, Manuscript No. JACR-22-18521 (R); Published: 05-Aug-2022 , DOI: 10.35248/2155-6148.22.13.1076

Copyright: © 2022 Anastase DM, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

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