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COM

Regional Anesthesia for

Total Joint Arthroplasty
DAVID A. PROVENZANO, MD
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Executive Director
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Institute for Pain Diagnostics and Care

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Ohio Valley General Hospital

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McKees Rocks, Pennsylvania

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EUGENE R. VISCUSI, MD
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Director, Acute Pain Management

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Department of Anesthesiology
Thomas Jefferson University
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Philadelphia, Pennsylvania
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Dr. Provenzano has consulted for Janssen Global

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Services, LLC, and Medtronic, and received

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honoraria from Cadence Pharmaceuticals.

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Dr. Viscusi has received research funding from

AcelRx, Adolor/Cubist, Cumberland, and Salix;
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consulted for AcelRx, Cadence, Cubist, Incline,

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and Pacira; and received honoraria from Cadence

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and Merck.
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atients undergoing total joint arthroplasty (TJA) experience
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high levels of pain after surgery that often interferes with

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their functional recovery and sleep patterns in the postoperative

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period.1 In one study, patients undergoing total hip arthroplasty (THA)

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and total knee arthroplasty (TKA) reported mean worst pain severities of
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7.6 and 8.1 on a 10-point scale, respectively.1 Numerous techniques have

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been developed for anesthesia and analgesia in an effort to optimize

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perioperative pain control, patient satisfaction, and functional recovery.

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Because clinician preference strongly influences patient selection and

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decision making, anesthesiologists and orthopedic surgeons must

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understand the current literature and level of evidence for each technique.2
This article provides an updated review of the evidence for regional
anesthesia for TJA surgery with an emphasis on the risks and benefits of
each technique for intraoperative anesthesia and postoperative analgesia.

I N D E P E N D E N T LY D E V E L O P E D B Y M C M A H O N P U B L I S H I N G A N E ST H E S I O LO GY N E WS S P E C I A L E D I T I O N • O C TO B E R 2 0 1 2 59
 (DVT) and pulmonary embolism (PE).3 It is important to
Table 1. Methods of Postoperative note that many of the studies in this review that favored
Pain Control for Total Joint regional anesthesia over general anesthesia in the reduc-
Arthroplasty tion of vascular events were earlier trials that examined
individuals who were not receiving anticoagulation pro-
phylaxis. A review of general and regional anesthesia
Intravenous opioids (IV-PCA)
for THA that contained research from 1966 to August
Oral opioids 2005, suggested that neuraxial block decreased the inci-
dence of radiographically diagnosed DVT and PE, and
Nonopioid analgesics decreased operative time by 7.1 minutes and intraopera-
tive blood loss by 275 mL.4
Neuraxial anesthesia and analgesia
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Contemporary reviews that examined only papers

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• Spinal–intrathecal opioids from 1990 onward have provided evidence for improve-
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ment in pain control but do not always demonstrate

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• Epidural–continuous infusion improvements in cardiovascular outcomes and mortal-

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ity. One systematic review of studies published since

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• Epidural–single-injection EREM
1990 found insufficient evidence from randomized con-
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trolled trials to conclude that anesthetic technique

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Single and continuous peripheral nerve blocks

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affected mortality, cardiovascular morbidity or inci-

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• Femoral nerve block dence of DVT and PE in patients undergoing THA.5

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In addition, regional anesthesia did not reduce hospi-

• Sciatic nerve block
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tal length of stay or facilitate rehabilitation. In 2009, a

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• Lumbar plexus block systematic review that examined contemporary litera-

ture on randomized controlled trials of TKA published
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EREM, extended-release epidural morphine; since 1990 found insufficient evidence to conclude that
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PCA, patient-controlled analgesia

anesthesia technique influenced mortality, cardiovascu-
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lar morbidity, or incidence of DVT and PE when using

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thromboprophylaxis.6
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TJA is performed with either a primary regional or Anesthetic choice also has been shown to affect
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general anesthetic technique. Many methods exist for other important outcomes, in addition to pain control,
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continued perioperative pain control (Table 1). In some including rates of surgical site infection (SSI) and med-
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cases, various modalities will be combined in an effort ical costs. In a retrospective review of more than 3,000
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to optimize pain management. Each method for pain knee or hip arthroplasty surgeries, Chang and col-
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control is associated with specific benefits, risks, side leagues, demonstrated a significant reduction in 30-day
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effects, economic implications, patient satisfaction lev- SSI rates—1.2% for epidural or spinal anesthesia versus
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els, and labor requirements for the health care team. 2.8% for general anesthesia.7 The odds of an SSI occur-
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ring in a patient receiving general anesthesia were 2.2

General Versus Regional Anesthesia for Total times greater than when neuraxial anesthesia was used.
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Joint Arthroplasty Proposed mechanisms for possible reduction in surgical

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Several advantages have been suggested for the use site infections with neuraxial anesthesia include modu-
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of neuraxial anesthesia for TJA surgery. These include lation of the inflammatory response, vasodilation and
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modification of the hypercoagulable surgical state, improvement in tissue oxygenation, and improvements
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improvements in regional blood flow, improvement in in postoperative analgesia.8

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pain control, and reduction in the surgical neuroendo- Spinal anesthesia has been shown to be more cost-
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crine stress response (Table 2). From the surgeon’s per- effective for TJA. Gonano and colleagues randomized
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spective, spinal anesthesia also provides ideal operating 40 patients to receive either spinal anesthesia or gen-
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conditions—profound muscle relaxation—moderate eral anesthesia and examined the costs of drugs and
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hypotension, which reduces blood loss, and the poten- supplies for both the chosen anesthetic and associated
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tial for faster room turnover. recovery.9 They found that spinal anesthesia was asso-
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Recent systematic reviews have examined the influ- ciated with lower fixed and variable costs, resulting in
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ence of the anesthetic choice for TJA surgery on out- a 48% savings (excluding expenditures for personnel)
comes. Reviews that included dates from 1966 onward compared with general anesthesia.
suggest that neuraxial anesthesia improves specific end-
organ outcomes and postoperative pain control. In a Regional Techniques for Postoperative
meta-analysis specifically examining neuraxial regional Analgesia for Total Joint Arthroplasty
anesthesia for TJA, regional anesthesia was associated Several analgesic techniques exist for postoperative
with significant reductions in operating time, need for pain management for TJA surgery. Each regional anes-
transfusions, nausea and vomiting, and incidence of thetic technique has specific advantages and disadvan-
thromboembolic disease including deep vein thrombosis tages. Selection of the appropriate technique is best

60 I N D E P E N D E N T LY D E V E L O P E D B Y M C M A H O N P U B L I S H I N G
guided through an understanding of the associated
risk–benefit profile of each technique and the pain man- Table 2. Physiologic Sequelae of the
agement needs for the specific clinical situation. Neuroendocrine Stress Response
INTRATHECAL OPIOIDS Hyperactivity of the autonomic nervous system
One analgesic approach that requires only minor
modifications in the anesthetic plan is the addition of Increased cardiovascular stress
intrathecal opioids to the spinal injection of local anes- Dysfunction in respiratory mechanics
thetic. Typically, intrathecal morphine will be added in a
dose range from 0.2 to 0.3 mg. For THA and TKA, intra- Decreased muscle protein synthesis
thecal morphine has been shown to improve patient
Elevated metabolic rate with an associated pro-
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satisfaction compared with IV patient-controlled anal- tein catabolic state

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gesia (IV-PCA) with opioids. However, intrathecal mor-

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phine only reduced the supplemental postoperative Increased formation of blood clots
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PCA morphine requirements for the patients undergo-

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Slower return of bowel function

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ing THA.10
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When intrathecal opioids are administered, additional

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Impaired immune function

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forms of pain control are needed to control “break-

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through pain” and for pain that outlasts the duration

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of the therapy. Respiratory monitoring also is required

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when intrathecal opioids are administered. associated with a lower incidence of side effects, includ-
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ing nausea and vomiting, urinary retention, and arte-

EPIDURAL ANALGESIA
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rial hypotension. Single and continuous lumbar plexus

Epidural analgesia with a single injection of extended- blocks also have been employed for postoperative
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release epidural morphine (EREM) or continuous epi- analgesia. A lumbar plexus block is performed with the
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dural infusions with local anesthetics can be effective goal of anesthetizing additional nerve branches (lateral
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methods of pain control in patients undergoing joint femoral cutaneous, femoral, and obturator nerves) that
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surgery. When specifically examining the use of epidur- innervate the surgical area. A continuous lumbar plexus
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als for TJA compared with IV-PCA, epidural analgesia block was found to be superior to IV-PCA for pain man-
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has been shown in high-quality studies to improve pain agement, with a reduction in morphine consumption,
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relief and recovery time.11,12 A Cochrane Collaboration improvement in pain control, and patient satisfaction.18
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review demonstrated that epidural analgesia for pain Although the lumbar plexus nerve block provides
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relief following TJA in comparison to systemic analge- effective analgesia, recently published guidelines from
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sia was beneficial, but its effects may be limited only to the American Society of Regional Anesthesia and Pain
the early postoperative period, 4 to 6 hours.13
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Medicine for patients receiving antithrombotic therapy

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Use of EREM has been studied in patients undergo- circumscribe its use.19 The new guidelines state that the
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ing TKA and THA. Compared with IV-PCA, the patients same precautions should be applied to deep periph-
treated with EREM for TKA required significantly less eral nerve catheters as neuraxial techniques. Alterna-
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postoperative opioids and had reduced mean pain tives to the lumbar plexus block have been investigated,
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intensity recall scores.14 For THA surgery, EREM demon- including a continuous femoral nerve block (CFNB). In
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strated improved pain control at rest to 48 hours post- one study, Ilfeld and colleagues compared a continuous
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dose and improvement in pain control ratings15; 25% of posterior lumbar plexus nerve block with a CFNB.20 The
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THA patients who received EREM did not require sup- femoral nerve-stimulating catheter was advanced up to
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plemental analgesia. 15 cm beyond the tip with the goal of obtaining cov-
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erage of the obturator and lateral femoral cutaneous

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Regional Techniques for Postoperative nerves. Pain control was equivalent for these 2 meth-
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Analgesia for Total Hip Arthroplasty ods. The CFNB was associated with shorter ambulation
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THA is associated with a high level of postopera- distances the morning after surgery, suggesting greater
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tive pain, although perhaps less than TKA. Many tech- impairment in the quadriceps femoris muscle.
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niques for administering regional anesthesia have been

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explored for THA to improve pain control.16 These Regional Anesthesia for Total Knee
include neuraxial analgesia, peripheral nerve blocks Arthroplasty
(PMBs), and EREM. Singelyn and colleagues compared
IV-PCA with morphine, continuous epidural analgesia, PERIPHERAL NERVE BLOCKS
and continuous femoral nerve sheath block for post- PNBs, including single-injection and continuous PNB
operative analgesia in THA.17 The authors found no catheters (CPNBC), have received substantial atten-
difference in quality of pain relief, postoperative hip tion as alternatives to neuraxial analgesia and systemic
rehabilitation, and duration of hospital stay for any of opioids for TKA. Some of the emphasis on PNBs arises
these approaches. The continuous femoral block was from concerns about concurrent anticoagulation and

A N E ST H E S I O LO GY N E WS S P E C I A L E D I T I O N • O C TO B E R 2 0 1 2 61
 Although a femoral block does improve postopera-
tive pain control for TKA, 60% to 80% of patients still
will complain of clinically significant pain. In an attempt
to improve pain control, single and continuous sciatic
nerve blocks can be administered. Evidence is mixed
for the analgesic benefits of adding a single-injection
or continuous catheter sciatic nerve block to a femoral
nerve block technique. In addition, no consensus has
been reached on whether a sciatic nerve block should
be performed for all TKA cases in which a femoral nerve
block also is performed.23 Neither a single-injection nor
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a continuous catheter sciatic nerve block is without the-

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oretical risks and possible disadvantages, including the

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prevention of the early detection of compartment syn-

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drome or neurologic injury resulting from surgery and

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the further impairment of motor function, thus imped-

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ing physical therapy during its duration of action. Some

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of the hesitation to perform sciatic nerve blocks is

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related to the risk profile of the procedure and the sur-

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gical vulnerability of the nerve. Sciatic nerve injury after

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TKA, not related to regional anesthetic technique, is a

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known complication.
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Figure. An ultrasound-guided right- Two randomized controlled trials24,25 and a recent

systematic review26 have attempted to address whether
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sided femoral nerve block. The red

blocking the sciatic nerve is advantageous for post-
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arrows delineate the placed needle. operative pain control and other related clinical out-
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The triangle-shaped femoral nerve is

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comes following TKA. In one trial, patients undergoing

lateral to the femoral artery (FA).
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TKA were randomized to 1 of 3 groups: a femoral nerve

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catheter, a femoral catheter combined with a single

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injection, or a femoral catheter plus a continuous sci-

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atic nerve block.25 The addition of a single-injection

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neuraxial anesthesia. The employment of low-molecu- sciatic nerve block to the CFNB reduced postopera-
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lar-weight heparin for DVT prophylaxis has limited the tive pain on the day of surgery. The continuous sciatic
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use of epidurals for postoperative analgesia. Although nerve block reduced moderate pain during mobilization
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CPNBCs have been advocated as a means of prolong- on the first 2 postoperative days. A sciatic nerve block
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ing the duration of action of single-injection nerve did not influence time to discharge readiness. In a sec-
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blocks, debate still continues on their advantages and ond study, Pham Dang and colleagues demonstrated
disadvantages compared with single-injection blocks. improvements in pain control with a continuous sciatic
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nerve block during the first 36 postoperative hours.24

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FEMORAL AND SCIATIC NERVE BLOCKS A recent systematic review, examining 4 interme-
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The most commonly used PNBs for TKA are femo- diate-quality randomized and 3 observational studies,
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ral and sciatic (Figure). In 2010, Paul et al performed a established that there is inadequate evidence to define
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meta-analysis of randomized controlled trials that com- the role of adding a sciatic nerve block, and could not
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pared a femoral block with or without a sciatic nerve demonstrate a benefit in analgesia beyond 24 hours.26
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block with PCA or epidural analgesia.21 Compared with Unlike a CFNB, continuous sciatic nerve blocks have
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PCA alone, a femoral block reduced morphine con- not been shown to improve functional outcomes or
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sumption at 24 and 48 hours, pain scores with activity decrease time until discharge readiness.23,25
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(but not at rest) at 24 and 48 hours, and the incidence With the current level of evidence for a sciatic nerve
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of nausea. No further improvements were found with block, one method to determine its implementation
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the addition of a CFNB. Although the femoral nerve could be to observe the patient during early recovery
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does not innervate the posterior portion of the knee, in to see if he or she is experiencing significant pain from
this meta-analysis a single-jnjection sciatic nerve block the posterior aspect of the knee that is not relieved by
did not offer a pain control advantage. the femoral nerve block. If so, the analgesia could be
In a recent trial comparing a single-injection femo- augmented with a single-injection sciatic nerve block.
ral block to CFNB for TKA, pain-intensity ratings were
improved during the first and second days after sur- Complications
gery.22 Opioid consumption and pain-intensity ratings Other factors that must be incorporated into deci-
during physical therapy also were significantly lower sion making for the anesthetic and analgesic technique
with a CFNB. for TJA include complications and adverse events. All

62 I N D E P E N D E N T LY D E V E L O P E D B Y M C M A H O N P U B L I S H I N G
the regional anesthetic techniques described above
have the following risks, including but not limited to Table 3. Complications/Adverse
bleeding, nerve damage, vascular injury, block failure, Events Associated With CPNBCs and
and infection. Neuraxial techniques and deep peripheral Time Frame of Occurrence
nerve catheters have been associated with devastating
bleeding complications. When opioids are incorporated

Insertion

Removal
Infusion
into neuraxial anesthesia, respiratory depression may
occur. Other opioid-related side effects also may result,
including sedation, pruritus, urinary retention, and post-
operative nausea and vomiting.27 The risks and compli- Neurologic injury Xa X X
cations specifically associated with CPNBCs are shown
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in Table 3. Vascular injury X X

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Although bacterial colonization may be common

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Local anesthetic toxicity X X

with certain catheters, the overall risk for infection is
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low. In one study, the incidence of bacterial colonization Migration/dislodgment X

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for femoral catheters was reported to be as high as 57%

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Infection X X X
when catheters were removed at 48 hours.28 Although
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3 cases of transitory bacteremia likely related to the

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Catheter knotting X X
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femoral catheters were reported, no patients developed

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an abscess or cellulitis. Catheter retention X

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Abscesses, cellulitis, and transient bacteremia have Secondary block failure X

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been reported with CPNBCs. The presence of diabetes

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Muscle weaknessb
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mellitus may increase the risk for infection. Appropri- X

ate steps to reduce the risk for infection include lim-
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a
X denotes most likely time frame of occurrence or
iting the duration of catheter use and following strict
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presentation.
aseptic guidelines. Another potential hazard of CPN-
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Muscle weakness may put patients at risk for falls or delay
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BCs that has received significant recent attention is physical therapy after a knee or hip arthroplasty.
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the association between lower-extremity blocks and CPNBCs, continuous peripheral nerve blocks
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patient falls.29-31 Continuous PNBs are associated with

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muscle weakness that may lead to falls or that can delay

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rehabilitation. Lower-extremity nerve blocks have been

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shown to impair the maintenance of limb stiffness, alter selection of perioperative pain treatment based on effi-
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proprioception, and decrease lateral stability.32 Post- cacy, safety, and patient satisfaction. The economic
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operative protocols should be in place to safely and implications and labor requirements of each technique
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appropriately manage quadriceps weakness associated also should be further explored.

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with femoral nerve blocks in the postoperative period.

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References
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In addition, the selected postoperative pain manage-

ment technique should be tailored to allow for early 1. Strassels SA, Chen C, Carr DB. Postoperative analgesia: economics,
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rehabilitation following TJA. Early intensive rehabili- resource use, and patient satisfaction in an urban teaching hospi-
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tal. Anesth Analg. 2002;94(1):130-137.

tation following TKA (ie, starting rehabilitation within
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2. Webster F, Bremner S, McCartney CJ. Patient experiences as

24 hours) has been shown to improve muscle strength, knowledge for the evidence base: a qualitative approach to
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range of motion, and pain by the time of discharge from

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understanding patient experiences regarding the use of regional

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the hospital.33 anesthesia for hip and knee arthroplasty. Reg Anesth Pain Med.
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2011;36(5):461-465.
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Conclusion 3. Hu S, Zhang ZY, Hua YQ, Li J, Cai ZD. A comparison of regional

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and general anaesthesia for total replacement of the hip or knee:

TJA is associated with significant levels of postop-
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a meta-analysis. J Bone Joint Surg Br. 2009;91(7):935-942.

erative pain. An appropriately selected anesthetic and
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4. Mauermann WJ, Shilling AM, Zuo Z: A comparison of neuraxial

analgesic plan will positively influence pain levels and block versus general anesthesia for elective total hip replacement:
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function after the procedure. To obtain optimal results a meta-analysis. Anesth Analg. 2006;103(4):1018-1025.
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with regional anesthetic and analgesic techniques, 5. Macfarlane AJ, Prasad GA, Chan VW, Brull R. Does regional anaes-
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these therapies should comprise one facet of a multi- thesia improve outcome after total hip arthroplasty? A systematic
review. Br J Anaesth. 2009;103(3):335-345.
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opioid analgesics and the inclusion of a structured 6. Macfarlane AJ, Prasad GA, Chan VW, Brull R. Does regional anes-
thesia improve outcome after total knee arthroplasty? Clin Orthop
rehabilitation program. A massive increase in the num- Relat Res. 2009;467(9):2379-2402.
ber of patients undergoing TJA surgery in the United 7. Chang CC, Lin HC, Lin HW, Lin HC. Anesthetic management and
States is expected to occur over the next 2 decades; surgical site infections in total hip or knee replacement: a popula-
by 2030, it is estimated that nearly 3.5 million primary tion-based study. Anesthesiology. 2010;113(2):279-284.
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22. Salinas FV, Liu SS, Mulroy MF. The effect of single-injection femoral
10. Rathmell JP, Pino CA, Taylor R, Patrin T, Viani BA. Intrathecal mor- nerve block versus continuous femoral nerve block after total knee
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knee arthroplasty. Anesth Analg. 1998;87(1):88-92. 24. Pham Dang C, Gautheron E, Guilley J, et al. The value of adding
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25. Wegener JT, van Ooij B, van Dijk CN, Hollmann MW, Preckel B,
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Stevens MF. Value of single-injection or continuous sciatic nerve

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13. Choi PT, Bhandari M, Scott J, Douketis J. Epidural analgesia for block in addition to a continuous femoral nerve block in patients
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15. Viscusi ER, Martin G, Hartrick CT, Singla N, Manvelian G, EREM 27. Neal JM, Rathmell JP. Complications in Regional Anesthesia & Pain
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morphine formulation. Anesthesiology. 2005;102(5):1014-1022. 28. Cuvillon P, Ripart J, Lalourcey L, et al. The continuous femoral
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29. Ilfeld BM, Duke KB, Donohue MC. The association between lower
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patient-controlled analgesia with morphine, continuous epidural

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analgesia, and continuous femoral nerve sheath block on rehabili-

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tinuous lumbar plexus block provides improved analgesia with

fewer side effects compared with systemic opioids after hip
or

31. Sharma S, Iorio R, Specht LM, Davies-Lepie S, Healy WL.

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19. Horlocker TT, Wedel DJ, Rowlingson JC, et al. Regional anesthe-
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American Society of Regional Anesthesia and Pain Medicine Evi- associated with lower-extremity-nerve blocks: a pilot investigation
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33. Labraca NS, Castro-Sánchez AM, Matarán-Peñarrocha GA, Arroyo-

20. Ilfeld BM, Mariano ER, Madison SJ, et al. Continuous femoral ver- Morales M, Sánchez-Joya Mdel M, Moreno-Lorenzo C. Benefits of
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sus posterior lumbar plexus nerve blocks for analgesia after starting rehabilitation within 24 hours of primary total knee arthro-
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plasty: randomized clinical trial. Clin Rehabil. 2011;25(6):557-566.

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