Anesthetic Options for Hip and Knee Replacements
You might think that a surgery as complicated as knee or hip replacement requires general anesthesia, which renders a person unconscious and necessitates a multi-day hospital stay. But it’s not necessarily so. A growing body of evidence shows that regional anesthesia may be the better choice for most people. A large-scale analysis from the National Joint Registry in the United Kingdom published last year in the Journal of Arthroplasty compared general anesthesia to regional anesthesia in 779,491 people undergoing either total hip replacement (THR) or total knee replacement (TKR). About 70% of people received regional anesthesia and the remaining 30% underwent general anesthesia.
The researchers examined what happened 90 days after the procedure and found using regional anesthesia reduced the length of hospital stays, readmissions, and complications.
“The vast majority of our joint replacements are done using regional anesthesia,” says Natale Naim, MD, associate clinical professor in the Department of Anesthesiology and Perioperative Medicine at UCLA Medical Center. “In most cases, people have the surgery and return home the same day.”
In addition, patients are not waking up nauseous, confused, and dizzy like they might with general anesthesia. Other advantages to regional anesthesia use include less blood
loss, improved pain control after surgery, and reduced risk of serious medical complications, such as heart attack or stroke that, although rare, may occur with general anesthesia.
Most, but not all people, are eligible for this type of regional anesthetic approach.
“There are guidelines regarding how long blood thinners need to be held before surgery, and some people may not be able to meet that criteria,” explains Dr. Naim. “There also are a few neurological disorders that inhibit the use of regional anesthesia.”
Preventing Pain Before, During, and After
Regional anesthesia blocks nerve signals to prevent pain in a select part of the body during surgery, much like Novocaine does for dental procedures. For THR and TKR a spinal/ epidural is injected to numb the body from the waist down. And while you could technically be awake during the process, most people wouldn’t want to be, says Dr. Naim. Instead, she says, you’ll be sedated and get the best nap of your life.
Another key part of the joint replacement process is the skillful use of targeted nerve blocks before, during, and after the procedure. The anesthetic medications are injected around specific nerves that prevent pain impulses from reaching the central nervous system. Depending on the type used, they can last from 12 to 36 hours. “Nerve blocks help prevent the brain from seeing the pain, which reduces the overall pain response and minimizes the conversion to chronic pain at the three-month post-surgery mark,” explains Dr. Naim.
At-Home Pain Relief
After discharge from UCLA Medical Center, people go home with a portable anesthetic pump that continues to deliver local anesthetic to the new joint around the clock for four days after the surgery, at which time the device can be pulled out at home. UCLA Health first adopted the take-home nerve catheter approach in 2014, and Dr. Naim estimates that across all surgical services it is used in approximately 1,500 procedures per year, significantly more than at most other medical centers. Following this protocol typically offers better pain relief and quicker recovery. And while some pain relief will likely be needed during the days and weeks after surgery, most people are able to rely on non-narcotic treatments.
Unlike opioid medications that affect the entire body, non-narcotic portable pumps deliver anesthetic medication directly to the site of pain. Even though opioids can be effective in postoperative pain management, they carry significant risks in older people, including over-sedation, constipation, an increased risk of falls, and addiction potential.
Choosing Wisely
Hip and knee replacements are one of the most common surgeries in America today. Nonetheless it’s still important to weigh the risks and benefits, discuss surgical options, and find an experienced surgeon you feel you can trust. If surgery is indicated, sooner is better than later. According to a recent study published in the Journal of Bone & Joint Surgery, waiting too long may cause limitations in physical activity that increase the risk of additional disability and chronic disease. While surgery can be scary, the use of new techniques has improved outcomes and reduced recovery and rehab time for many people. “Medicine is advancing in great directions,” says Dr. Naim. “This is one them.”
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