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    General Anesthesia Is Safe and Effective for TJA Patients, Even in Rapid Recovery Protocols

    Editor’s Note: Research papers intended for presentation at the canceled annual meeting of the American Academy of Orthopaedic Surgeons are now available online at the AAOS Virtual Education Experience. We’ll be highlighting a few of the more interesting papers throughout the summer.

    Rapid recovery protocols – particularly those followed at high-volume institutions – typically include the use of spinal anesthesia for patients undergoing total joint arthroplasty to facilitate quick, safe discharge. General anesthesia is rarely included in these protocols.

    But according to a study from the University of Arkansas for Medical Sciences (UAMS), that may be a mistake: Today’s general anesthesia regimens, which include multimodal anesthesia and shorter-acting paralytics, are safe and effective when administered to total joint arthroplasty patients, allowing these patients to be discharged according to an institution’s rapid recovery protocol without a large number of complications or readmissions or a prolonged length of stay.

    The study authors retrospectively reviewed data on 1527 patients who underwent elective total joint arthroplasty (883 total knee arthroplasty, 644 total hip arthroplasty) at UAMS between June 2015 and June 2018. The procedures were performed by 4 fellowship-trained orthopaedic surgeons. All patients received general anesthesia and analgesics according to the institution’s multimodal protocol:

    • Preoperatively: Celecoxib, acetaminophen, oxycontin, and midazolam
    • Induction of general anesthesia: Fentanyl, lidocaine, propofol (etomidate if propofol is contraindicated), and succinylcholine (rocuronium if succinylcholine is contraindicated)
    • Intraoperatively: Sevoflurane (propofol infusion if sevoflurane is contraindicated), local infiltration with bupivacaine, dexamethasone, fentanyl, ondansetron
    • Postoperatively – PACU (based on VAS pain score): 7-10: fentanyl, 4-6: roxicodone, 1-3: acetaminophen
    • Postoperatively – orthopaedic unit: Pain 8-10: oxycodone, pain 4-7: hydrocodone/acetaminophen, acetaminophen every 6 to 8 hours, ice around the clock

    On the day of surgery, postoperative patients worked with a physical therapist on gait training with a walker, quad sets, and range of motion exercises. Patients admitted to the orthopaedic unit too late to work with a physical therapist were prioritized for physical therapy early in the morning on POD1.

    Most patients were discharged on POD1 (1471 patients, 96.3%). Of those, 1482 patients (97.2%) had participated in physical therapy on the day of surgery. Only 56 patients had a prolonged length of stay (more than 1 day) due to various surgical-, anesthesia-, and medical-related complications, such as slow progression in physical therapy, acute blood loss anemia, and cardiovascular events. Six patients (0.4%) had an unplanned admission to the ICU postoperatively.

    The 90-day readmission and reoperation rates were also low at 2.4% (n=36) and 1.3% (n=20), respectively. The most common surgical cause of readmissions was periprosthetic joint infection, which was also the most common reason for reoperation.

    The study authors said their findings demonstrate that “implementation of a modern rapid-recovery general anesthesia protocol that limits narcotics and long-acting inhalant gases for elective [total joint arthroplasty] can have excellent outcomes with limited complications or adverse events.

    “Furthermore, the results suggest that the use of contemporary [general anesthesia] practices is safe and efficient in centers that perform a high volume of elective, primary [total joint arthroplasty] and dispute the notion that [spinal anesthesia] is absolutely superior in terms of hospital stay or participation in early mobilization.”

    Sources

    Stambough JB, Bloom GB, Edwards PK, Barnes CL, Mears S. The Safety and Efficacy of Rapid Recovery Total Joint Arthroplasty Utilizing General Anesthesia. Paper 230. AAOS Virtual Education Experience.

    Stambough JB, Bloom GB, Edwards PK, Mehaffey GR, Barnes CL, Mears S. Rapid recovery after total joint arthroplasty using general anesthesia. J Arthroplasty. 2019 Sep;34(9):1889-1896. doi: 10.1016/j.arth.2019.04.066. Epub 2019 May 9.