**5.2 Total hip arthroplasty injection technique**

A standard approach can be undertaken to local anaesthesia administration intraoperatively can be adopted regardless of approach used (anterior/posterior/ lateral). The primary purpose is to provide anaesthesia to all area affected by the trauma of the surgery. The total volume used intraoperatively of anaesthetic mixture is 150-200 mL where three main stages of administration are involved.


This epidural catheter is then attached to either an antibacterial filter if the intention is post-operative bolus application of anaesthetic mixture or continuous elastomeric pain pump.

### **5.3 Total knee arthroplasty injection technique**

As with hip arthroplasty, in knee arthroplasty the aim is to infiltrate local anaesthetic mixture into areas affected by the surgery. General principals can be broken into four main stages.


away from the popliteal artery. Once the definitive implants are inserted structures around medial collateral ligaments, quadriceps, and tibial portion of the iliotibial band. The epidural catheter is placed through the skin, fascia, quadriceps, and joint capsule using a Tuohy needle, then inserting the tip of the wound catheter posterior to the medial femoral condyle. Also, as was mentioned with hip arthroplasty, care must be taken when closing the wound not to catch catheter with sutures which will impede catheter removal.


An alternate catheter placement can be within the adductor canal, performed intraoperatively. Adductor canal catheter placement may be performed under direct visualisation on subvastus approach. In recovery, ice pack should be applied hourly for 20-minute intervals for the first four hours to prevent swelling and assist in pain control.

#### **5.4 Post-operative**

#### *5.4.1 Continuous infusion vs. bolus in LIA*

The evidence favouring continuous, or bolus post-operative catheter regimes is limited. Early development by Kerr & Kohen used a bolus protocol in THA and TKA, along with other published protocols [10, 14, 42, 49]. Ballarat experience in their study published in ANZ Journal of Surgery in 2020 supported that bolus injection demonstrated better outcome. However, there is also evidence to support the use of continuous infusions of anaesthetic mixture delivered by elastomeric pump devices post operatively which has also shown success [50–52]. Typically, the infusion rate of 5 ml per hour for 48 hours if continuous infusion is used.

Our preference is 25 ml LIA cocktail without adrenaline is injected in the morning after surgery as a bolus.

#### *5.4.2 Post-operative bandage*

Compressive bandage applied post-operatively prolongs the local anaesthetic within the peri-articular tissues after TKA. An elastic binder compressing a sponge on the hip wound could be used but is not common practice and there is no evidence for efficacy. The bandage should be placed to have enough venous compression but not arterial compression [10].

A compression bandage is applied post operatively over the whole leg, from toes to high thigh, in three layers; one layer of soft padding, one layer of crepe bandage, and outer layer of elastic adhesive bandage as recommended by Kerr and Kohan in 2008 [10]. Another study confirmed the benefits of the compression bandage in TKA and demonstrated the improvement of LIA with compression bandage [53]. The compression dressing is removed 24–48 hours post operatively.

#### **6. Pillars of fast track Arthroplasty**

In recent times, many health care systems globally have undergone revision of their hip and knee arthroplasty pathways [40, 54]. The concept of ERAS, 'rapid recovery' or

#### *Fast Track Arthroplasty Using Local Infiltration Analgesia DOI: http://dx.doi.org/10.5772/intechopen.99433*

'fast-tracking' aims to reduce operation-related physiological and psychological stress as well as enhance early mobilisation and reduce recovery time [44]. Implementation of this rapid recovery model has resulted in reduced length of stay with no increase in hospital re-admissions [40, 43]. In recent times, many health care systems globally have undergone revision of their hip and knee arthroplasty pathways [40, 54]. The concept of ERAS, 'rapid recovery' or 'fast-tracking' aims to reduce operation-related physiological and psychological stress as well as enhance early mobilisation and reduce recovery time [44]. Implementation of this rapid recovery model has resulted in reduced length of stay with no increase in hospital re-admissions [40, 43].

Three stages are identified in a patient's journey: pre-operative, peri-operative and post-operative. Pre-operative patient education is a recognised cornerstone in rapid recovery programs [54], with particular attention paid to patient expectation management regarding post-operative pain and LOS. Simultaneously, pre-operative anaesthetic review allows assessment and modification of patient risk factors that have been shown to reduce length of stay in hip and knee arthroplasty patients [55].

#### **6.1 Preoperative**

Rapid recovery protocol begins at the pre-admission stage. On presentation to pre-admission clinic, patients require education on appropriate expectations regarding their operation and post-operative course. An assessment tool in assisting prediction on length of stay and discharge destination (i.e. home or rehabilitation facility) is the Risk Assessment and Prediction Tool (RAPT) which has been previously validated [56, 57]. This tool is a score from 0 to 12, the higher the score the better, where points are given based on age, gender, average walking distance, requirement for walking aids, community, and home supports. With RAPT score < 6 the patient will likely require rehabilitation, between 6 and 9 the patient will likely be discharged home and with a score greater than 9 the patient will likely be discharged post-operative day 1 [57].

There is minimal evidence relating to the impact of preoperative patient education where a Cochrane review by McDonald et al. found preoperative education had no measurable impact on preoperative anxiety or surgical outcomes including pain, function and adverse events [58]. McDonald et al. however noted that there was much heterogeneity and low-level evidence within included studies and preoperative education may benefit patients with depression, unrealistic expectations, anxiety or those with limited social support [58]. The authors believe that setting expectations preoperatively is extremely important for patients prior to their day of surgery where they understand arthroplasty will involve pain which cannot be completely removed, they will be mobilised day of operation, and the primary goal will be discharged home once they are deemed safe. Patients should be prepared to go home post-operative day one.

Pre-admission optimisation is another essential factor when preparing for hip and knee arthroplasty. Assessment and optimisation of risk factors including smoking, alcohol consumption, anaemia, nutritional and metabolic status, and low physical activity has been shown to have a positive impact on length of stay and postoperative complications [59]. Smoking has been shown to increase early post-operative complications, however there is level 2 evidence showing that cessation 4 weeks or greater preoperatively can improve post-operative complications especially related to wound healing [8]. Preoperative optimisation within fast-track protocols has also been shown to reduce the number of patients with a delayed recovery [59].

#### **6.2 Perioperative**

There are several factors that are considered in fast-track arthroplasty regarding preparation for surgery including fasting duration and carbohydrate loading.

#### *Topics in Regional Anesthesia*

Although now relatively common practice, anaesthetic guidelines no longer recommend prolonged fasting status, rather a 2 hour clear and 6 hour solid fasting status prior to surgery [60]. Although a component of fast-track/ERAS protocol, carbohydrate has mixed evidence on impact of clinical outcomes in hip and knee arthroplasty even though there some studies have shown positive impact on postoperative hunger, pain, glucose metabolism and insulin resistance [8].

Standardised anaesthesia is another component included in ERAS protocols with mixed evidence regarding superiority between neuraxial anaesthesia/regional and general anaesthesia [7, 8, 11]. Several studies showed the benefit of neuraxial/ regional anaesthesia including reduced pulmonary compromise, pulmonary embolism, need for transfusion, renal injury, infection, length of stay and 30-day mortality [61, 62]. Alternatively, a systematic review and meta-analysis by Johnston et al. found no difference between neuraxial and general anaesthesia [63]. In general, the aim with fast-track arthroplasty is to reduce systemic opioid use. This avoids associated side effects of opioid analgesia which can inhibit engagement in post-operative recovery by adopting effective multimodal analgesia and anaesthesia.

#### *6.2.1 Tranexamic acid*

There is potential for large blood loss with hip and knee arthroplasty which in turn can prolong hospital stay, increase risk of transfusion, renal failure and increase risk of deep infection. The inclusion of tranexamic acid in hip and knee arthroplasty is effective and safe medication which reduces blood loss with no increased risk of thromboembolic events [7, 8].

#### *6.2.2 Post-operative nausea and vomiting*

Post-operative nausea and vomiting (PONV) can be extremely distressing for patients which consequently impact their post-operative course. Risk factors include narcotics, inhalational anaesthesia, female sex, non-smoking status, history of motion sickness or previous PONV and predicted requirement for post-operative opioids [7]. Active screening and prophylactic treatment for at risk individuals is recommended, but our experience with Total Intravenous Anaesthesia (TIVA) or at least minimising inhalational anaesthesia suggests nausea and vomiting to be less common than it once was.

#### *6.2.3 Active intraoperative warming*

Maintaining normothermia must be a component of anaesthetic care for joint arthroplasty. When normothermia is maintained, it reduces infection, cardiac complications, transfusion requirements and coagulopathy [7]. With joint arthroplasty, aggressive warming has been shown to reduce intraoperative blood loss in total hip arthroplasty and reduce opioid requirements along with improved patient satisfaction in total knee arthroplasty [7]. Several techniques have been described to assist in maintain normothermia including warm IV fluids and irrigation fluid, prewarming and humidification of anaesthetic gases along with forced air-warming blankets and devices [8].

#### *6.2.4 Avoid urinary catheters*

With the use of low dose or no opioid spinal anaesthetic, urinary catheters are unnecessary for the majority of patients, avoiding bacteraemia which may increase

#### *Fast Track Arthroplasty Using Local Infiltration Analgesia DOI: http://dx.doi.org/10.5772/intechopen.99433*

risk of prosthetic joint infection [64]. A large RCT performed within a hip and knee arthroplasty ERAS program showed that increasing a catheterisation threshold from 500 ml to 800 ml over halved the incidence of catheterisation without increase in urological complications [64]. Routine use of urinary catheters is not recommended as per ERAS consensus statement for hip and knee arthroplasty and if used should be removed within 24 hours of insertion [8]. The catheter adds another line or attachment to the patient which increases risk of fall and does not facilitate early mobilisation. Lines should be removed as soon as possible to improve patients' psychological state and avoid any impediment to mobilisation. This not only pertains to urinary catheters but also applies to PCA and other IV lines unless required.
