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| Category #16 - The hip joint |
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| Lumbar plexus vs. epidural for Hip Surgery |
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Even when used for post-op analgesia in hip surgery, the lumbar plexus (psoas) block in my hands often fails, probably due to unblocked sacral nerve supplying the hip. At the moment, I am re-evaluating continuous epidural. May I please ask which is your preferred anesthetic plan for total hip arthroplasty?
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Thank you for this interesting question.
Primary total hip replacement is known to be more painful before surgery than after surgery. If it is painful after surgery, it is usually only painful for the first 24 hours and studies have shown that placebo works as well as anything else after 24 hours. My personal "default" technique for primary hip replacement is combined spinal epidural anesthesia.
I use the spinal part of it with 12-15 mg of bupivacaine and 25 micrograms of fentanyl (the fentanyl because I do not trust all our surgeons to be done within two hours). Intraoperatively, I then use sedation with appropriate dosages of meperadine 12.5 - 50 mg intravenously combined with appropriate dosages of Midazolam (1 - 2 mg every 15 to 30 minutes as necessary). We also intraoperatively provide the patient with noise cancellation headphones (Bosé) and music of the patient's choice via an iPod.
This we find very satisfactory intraoperatively and postoperatively. After the surgeon has evaluated the sciatic nerve for function by excluding drop foot, we then top up the epidural part of the CSE and use this for 24 hours postoperatively. Typically, our surgeons start using Coumadin (warfarin), the evening after surgery and that gives us ample time to remove the epidural catheter the next day after which time the patient can comfortably be managed with oral analgesic medication.
I trust that this information adds some value to your practice.
Kindest regards,
André Boezaart
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| Anesthesia for revision hip surgery |
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What is your preferred anesthetic plan for revision hip replacement surgery?
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Dear Colleague:
Thank you for asking this question.
Primary hip surgery is not painful because during the surgery the capsule of the joint is destroyed and with it, all the nerves that supply the joint. The joint is therefore denervated. It is therefore not surprising that patients do not complain of much pain after 24 hours following primary hip replacement.
Following revision hip replacement there is, however, scar tissue around the hip and the surgery is much more extensive than for primary hip surgery. The nerve tissue that formed inside the scar tissue produces severe post-operative pain. This post-operative pain is, however, not in the same category as that of total knee replacement, because during total knee replacement, the joint capsule is not destroyed.
There is very little data available on this, so I will revert to my personal experience and personal opinion. My preferred anesthetic technique to do a combined spinal epidural for these patients as I would for a primary hip replacement with the only difference that I would tend to leave the epidural catheter in as long as possible, while timing the removal of the catheter carefully to fit in with the thrombo-prophylactic plan. I encourage the surgeons to use enoxaparin rather than Coumadin (warfarin), at least for the first three days since a "window of opportunity" can be created to remove the catheter safely. It is however important to plan this removal of the catheter so that we comply with the European, American and other societies' recommendations.
Please feel free to ask any further question to any of the experts that are listed on the home page of the website, httt://www.RAEducation.com.
Kind regards,
André Boezaart
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What type of block do you use for hip surgery?
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There is a marked difference between primary hip surgery and revision hip surgery. During primary hip surgery the joint and joint capsule are removed, thus in fact denervating the hip. There is therefore remarkable little postoperative pain following primary hip surgery. This is not the case with revision hip replacement. Lumbar plexus catheters and epidural catheters are both effective means of providing hip analgesia, when anti-coagulation is not an issue. The technique I use for primary and revision total hip arthroplasty is combined spinal epidural anesthesia for the surgery and postoperative period. I leave the catheter in overnight and remove it the next morning before the warferin had a chance to take effect. Lumbar paravertebral is usually and "overkill" for primary hip replacement.
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What is your practice for hip fractures in the elderly?
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These patients are most often at their best just before the injury. From there they go downhill fast. So, I try to do their surgery as soon as possible. Ideally I place a femoral nerve catheter as soon as I can. The ER is the ideal place for this. This takes pain out of the equation and X-rays etc easier. When the patient reaches the OR, I place them on their sides, lying on the fracture, which is now pain free due to the femoral block, and I do a unilateral spinal with 1 mL heavy bupivacaine. This has about no hemodynamic implications and almost no patient is to sick to do like this. Remember to tunnel the femoral catheter away from the hip where the surgeon has to do his magic.
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