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  • ISSN: 2373-9290
    Special Issue on Modern Anesthesia Techniques for Total Joint Arthroplasty: from Blood Preservation to Modern Pain Control
    Special Issue entitled: Modern Anesthesia Techniques for Total Joint Arthroplasty: from Blood Preservation to Modern Pain Control
    Ran Schwarzkopf
    Assistant Clinical Professor
    Department of Orthopaedic Surgery
    University of California
    Irvine, USA
    Review Article
    Bryan M Saltzman1* and Julius K Oni2
    The rich vascularity of the hip and knee joints provides a substantial source of blood loss intra- and perioperatively during total knee or hip arthroplasty procedures. Due to concerns over postoperative anemia and the subsequent risks of transfusion of blood products, a push has been made in the Orthopedic and other surgical fields toward developing technology to provide superior intraoperative hemostasis. Standard unipolar electrocautery has been utilized for many years, but at the detriment of local tissue damage through charring and possibility of eschar detachment postoperatively and consequent repeat bleeding. Bipolar sealer devices were developed to produce hemostasis with radiofrequency energy in combination with continuously-flowing saline irrigation at the electrode tip to denature the vessel wall's elastin and collagen and cause contraction of vascular collagen, occlusion of blood flow, coagulation and subsequent soft tissue sealing at a much lower temperature (< 100°C) than with standard electrocautery. The advantage of electrothermal bipolar vessel sealers include diminished thermal injuries, reduced charring, less tissue necrosis, reduced time of operation, ease of visualization of vessels being sealed, no systemic morbidity risks (as may be seen with certain pharmacologic strategies), and the absence of foreign material left at the surgical site. However, the disadvantages include the cost of the device and the risk of thermal spread. Some studies comparing bipolar sealers to standard monopolar devices have reported superior results in reducing blood loss and transfusion risk, while other reports have shown equivocal outcomes, leading to questions regarding the cost-effectiveness of the technology.
    Wiramus Sandrine1, Delahaye David2*, Parratte Sébastien3 and Argenson Jean-Noël3
    Abstract: Total Joint Arthroplasty (TJA) increased by over 150% during the last ten years. Patient's satisfaction and comfort are essential for improving general health, quality of life and functional outcome after this surgery. The degree of this satisfaction is closely correlated with postoperative pain control and blood preservation techniques. Today, modern analgesia is based on the concept of multimodal analgesia: it is an association of drugs and other analgesic techniques used in combination to increase efficiency and/ or reduce side effects of the treatment. Multiple protocols have shown clinical benefits, but without the same efficacy. Loco-regional anesthesia has a clear role in multimodal analgesia, so, the different techniques are still under study and the efficiency of local anesthetic administration remains to be determined. Secondly, previously undiagnosed anaemia is common in elective orthopaedic surgical patients and is associated with increased likelihood of blood transfusion and increased perioperative morbidity and mortality. In this way, perioperative blood management protocols are necessary for early detection and management of anemia to improve patient outcomes. The goal of this review is to describe and define the profitability of the various modalities for pain control and blood preservation in total hip and knee arthroplasty.
    Slover J1*, Riesgo A1, Payne A1 and Umeh U2
    Abstract: Postoperative pain is a significant consequence of total joint arthroplasty that can affect early mobilization, joint range of motion, and length of stay. Inadequate pain control can also lead to secondary medical sequelae such as venous thromboembolic and cardiac events. Adequate control of pain following total joint arthroplasty is therefore paramount to a successful outcome and to patient satisfaction. Traditional postoperative analgesia with opioids or epidural anesthetics provides inconsistent results with significant side effects. Regional nerve blocks and multi-modal pain techniques have emerged as a way to address this issue. This review will consider the evidence for the use of regional nerve blocks for pain control after total knee and hip replacement, and examine the agents, administration routes and dosing protocols, along with the role of multi-modal analgesia in achieving optimal pain control after lower extremity joint arthroplasty.
    Stowers MDJ1,2*, Gao R1, Penumarthy R3 and Munro JT1,4
    Abstract: Knee replacement surgery has been associated with short-term morbidity that may impair postoperative recovery. Local anaesthetic delivered to the knee joint at the time of surgery has been touted as a way of attenuating post surgical pain, facilitating earlier engagement in rehabilitation and attainment of functional milestones. Arthroplasty surgeons use corticosteroids as part of their analgesic cocktail to enhance these properties. However, concern has been raised regarding the increased risk for infection and possible tendon rupture. Infection can be a devastating complication and many authors have questioned the safety profile of steroids when used in this manner. We aim to systematically review articles investigating the safety and efficacy of periarticular corticosteroids in knee replacement surgery.
    Research Article
    George N. Guild III1*, Rubin P Galindo1, Joseph Marino3, Fred D. Cushner2 and Giles R. Scuderi2
    Abstract:
    Introduction: Preoperative pain control after total knee athroplasty may be insufficient resulting in insomnia, antalgic ambulation, and difficulty with rehabilitation. Current strategies, including the use of femoral nerve catheters, may control pain but have been associated with falls, motor blockade, and quadriceps inhibition. Periarticular infiltration (PAI) with the appropriate technique and knowledge of intrarticular knee anatomy may increase pain control and maximize rehabilitation.
    Materials and methods: We reviewed current available literature using MEDLINE and other search engines regarding human knee innervation. Search terms included "knee innervations," "pain control," and other terms. Studies were excluded if they did not provide pertinent information on human knee innervation or studies that were not in English. We used this literature to summarize human knee innervations and relevant areas of increased mechanoreceptors with free nerve endings to systematically guide Periarticular infiltration.
    Results and discussion: Evidence from the literature supports the use of peri-articular injections for the relief of pain following total knee arthroplasty. Effective use of PAI requires acknowledge of the relevant neuroanatomy of the knee. Based upon a review of the literature we have identified eight areas around the knee that have a high number of nerve endings and should be infiltrated with the anesthetic agents. Concentrating the PAI injection to these areas with a long acting liposomal bupivacaine can aid in improving postoperative pain following total knee arthroplasty.
    Conclusion: Perioperative pain management with PAI and liposomal bupivacaine is a safe and effective method of controlling pain after total knee arthroplasty. The use of a systematic approach to periarticular injection with knowledge of intrarticular knee innervation may improve perioperative pain control after total knee arthroplasty, and decrease complications associated with femoral nerve blockade.:
    Nicholas Pulos1* and Neil Sheth2
    Total Joint Arthroplasty (TJA) has proven to be very successful in the treatment of patients suffering from end-stage osteoarthritis of the hip and knee [1,2]. The demand for primary TJAs is expected to dramatically increase over the next several years due to more procedures being performed annually, younger patients being considered candidates for surgery, and patients exhibiting longer life expectancies. It is predicted that the number of Total Hip Arthroplasties (THAs) in the United-States is estimated to grow to 572,000 and Total Knee Arthroplasties (TKAs) to 3.48 million by the year 2030 [3]. The current healthcare cost containment environment in conjunction with a more patient-centered and clinical outcomes approach emphasizes both patient satisfaction and patient throughput [4].
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