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Anesthesia for orthopaedic replacement surgeries. Prof.Dr.K.BALAKRISHNAN, Chennai. Introduction. Some of the common joint replacement surgeries are 1. Hip replacement 2. Knee replacement 3. Shoulder replacement 4. Elbow replacement.

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Anesthesia for orthopaedic replacement surgeries

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  • Some of the common joint replacement surgeries are

1. Hip replacement

2. Knee replacement

3. Shoulder replacement

4. Elbow replacement


Total knee replacement (TKR) and hip fracture coming for replacement are the two most common surgical procedures after the sixth decade of life.


Other conditions requiring knee or hip replacement are injury to the neck of femur or knee joint, knee deformity, rheumatoid arthritis and gout.

the challenge
The challenge….
  • Decreased organ function and reserve
  • Co-morbid conditions
  • Consequences of polypharmacy
challenges have been converted into good outcomes
Challenges have been converted into good outcomes…
  • Better understanding on pathophysiology of aging
  • Better pharmacotherapy
  • Safer anaesthetic techniques
  • Improvements in monitoring
  • Multimodal analgesia and site specific analgesia
  • Physiotherapy and early ambulation
pain is the first enemy to mankind

Pain is the first enemy to mankind….

And anaesthesiologists are

mankind’s guardian angels.


The straw that breaks the camel’s back may be a very small one when the camel is nearing the end of it’s journey !

pre operative concerns
Pre-operative concerns
  • Associated injuries
  • Cause for the fall
  • Difficulty in assessing cardio respiratory reserve
  • Osteoarthritis- Medications-NSAIDs
pre operative concerns15
Pre-operative concerns….
  • Pre-renal azotaemia
  • DVT prophylaxis
  • Diabetes Mellitus
  • The emotional significance of fracture to the geriatric patient must also be considered.
preoperative preparation
Preoperative Preparation
  • Evaluation of the functional cardiovascular reserves may be difficult due to the bedridden state, the confusion encountered, and the fracture. Simple steps (e.g., auscultation, ECG, and chest x-ray) can detect acute decompensation.
Echocardio­graphy if feasible at the bedside and can give useful information about left ventricular and valvular function.
  • Evaluation of electrolytes and blood count is required; anemia or electrolyte disturbances should be addressed prior to anesthesia induction.
prophylaxis against dvt
Prophylaxis against DVT
  • Prophylaxis against deep vein thrombosis after lowerlimb joint surgery is done with low molecular weight heparin starting either post operatively or 12 hours preoperatively .
intra operative concerns
Intra-operative concerns


General anesthesia

The choice of anaesthesia is determined by:

i) surgical factors

ii) Patients factors

iii) Estimates of risk associated with anaesthesia techniques

regional anesthesia advantages
Regional Anesthesia -Advantages
  • Stress response to surgery
  • Intraoperative blood loss
  • Post-operative hypoxia
  • PONV
  • DVT- early mobilization
regional anesthesia advantages22
Regional Anesthesia -Advantages
  • Preemptive analgesia
  • Post-operative analgesia

Hypostatic pneumonia

Pressure sores


Centri Neuraxis Block - Concerns

  • Coagulopathy
  • Conscious sedation
  • Shivering
  • Technical difficulty
  • Autonomic dysfunction
  • -Hypotension
  • I.V. fluids,
  • vasopressors,
  • Diastolic pressure 60 mm Hg
regional anesthesia techniques
Regional anesthesia techniques

- Spinal

- Epidural anesthesia

- Combined spinal epidural anaesthesia

- Femoral and Sciatic nerve blocks (especially in patients with fixed cardiac output in whom a neuraxial block is not preferred due to possible haemodynamic changes specifically profound hypotension).

The alternative option in fixed cardiac output states include segmental epidural, here the titrated doses of local anaesthetic administration and just blocking the segments involved offers the benefits of regional anaesthesia in critically ill patients and at the same time provides stable haemodynamics.
general anesthesia pre operative beta blockade
General anesthesia -Pre-operative beta blockade
  • CAD
  • Hypertension
  • Diabetes mellitus
  • Hypercholesterolemia
  • Renal dysfunction
  • Goal: Heart rate between 60-70.
general anesthesia pre oxygenation
General anesthesia -Pre-Oxygenation
  • 100% Oxygen
  • 8 deep breaths
  • Oxygen flow 10 L per min
general anesthesia choice of anesthetic agent
General anesthesia -Choice of Anesthetic agent

Short acting and less lipid soluble drugs

  • Propofol
  • Fentanyl
  • Rocuronium
  • Atracurium
  • Sevoflurane
  • Isoflurane
intra operative monitoring
Intra-operative monitoring

Pulse Oximetry

5 lead ECG-ST analysis




Neuromuscular monitoring

Urine output

blood transfusion

Blood Transfusion

Progressive reaming of femur and resection of the condyles is associated with steady blood loss

bone cement hypotension

Bone Cement- Hypotension

The placement of the prosthesis involve the use of methylmethacrylate

( bone cement )

The cementing can cause hemodynamic fluctuations

These fluctuations are related to the vasodilatory and mast-cell degranulating properties of the monomeric form of methylmethacrylate

bone cement implantation syndrome

Bone Cement implantation syndrome

Bonecementimplantation syndrome (BCIS) is poorly understood. It is an important cause of intraoperative mortality and morbidity in patients undergoing cemented hip arthroplasty and may also be seen in the postoperative period in a milder form causing hypoxia and confusion.

bone cement implantation syndrome treatment

Bone Cement implantation syndrome - Treatment

BCIS may be reversible with prompt basic life support and treatment to maintain both coronary perfusion pressure and right heart function.

Administer fluid volumes to augment right ventricular preload. Direct acting vasopressors, such as phenylephrine and norepinephrine can be titrated to restore adequate aortic perfusion

To improve ventricular contractility and function administer inotropes such as dobutamine.

fat embolism
Fat embolism

The high incidence of fat embolism with femoral neck fracture repair and cemented endoprosthesis may contribute to pulmonary dysfunction

tourniquet in knee replacement
Tourniquet in knee replacement

Tourniquet inflation:

may precipitate heart failure

may cause hypotension after release of tourniquet

due to:

Release of acid products

Affected limb getting filled with blood

Blood loss

post operative care
Immediate postoperative care should be directed to supporting oxygenation, controlling pain, and facilitating the patient's return to the baseline mental status by emphasizing orientation. Post-operative care
post operative concerns






Post-operative concerns
Postoperative pain therapy is best a multimodal approach.

- local anaesthetic infusions through perineural catheters supplemented with analgesics including a combination of paracetamol, tramadol, NSAID(when there is no contraindication) and opioids.



No.1: Start with low dose

Avoid long acting drugs

No.2: Use standing dose regimens

No.3: Repeated reassessment of pain relief

No.4: Repeated reassessment of side effects

No.5: Educate/inspire the care giver

post operative concerns41
Post-operative concerns
  • Post operative delirium
  • Post operative hypoxemia
  • Hyponatremia
  • Hypoglycemia

Early Mobilisation

Psychological support

Peri-operative Sepsis

Peri- operative Antibiotics

  • Geriatric patients for joint replacement surgeries offer a great challenge to the anaesthesiologists.
  • A careful preoperative examination, preoperative optimization, safe intraoperative anaesthetic techniques, good postoperative pain relief, good postoperative followup with rehabilitation would aid in decreasing the morbidity in these patients.