10/18/12

Knee Replacement Revision without General Anesthesia?

An orthopedic surgeon discusses anesthesia options for knee revision surgery.

Are you wondering if general anesthesia is absolutely necessary for knee revision surgery? 

“Knee revision can be done under regional (spinal, epidural, femoral/sciatic block) with sedation, depending on the efficiency of the surgeon and the skills of the anesthesiologist,” says Henry Boucher, MD, clinical instructor of Adult Reconstruction, Medstar Union Memorial Orthopaedics, Baltimore, MD.

“There is some controversy whether the DVT/PE rates are lower with regional some studies show), but it is a commonly held belief,” adds. Dr. Boucher.

Reasons why a patient should have general anesthesia for knee revision surgery (or primary replacement):
Dr. Boucher explains, “Contraindications (to regional anesthesia) include elevated risk of bleeding (use of anticoagulants); certain cardiac conditions (severe aortic stenosis) where a drop in blood pressure due to proximal migration of the spinal would be very risky; some patients with extensive spinal surgery.”

Why would some surgeons prefer general anesthesia for knee replacement or revision surgery in a patient without any contraindications?
Dr. Boucher explains, “Some surgeons are reluctant to agree to regional because of 1) the time it takes to place and 2) time to achieve proper anesthesia.

“The flip side is that it can save time at the end of the case since there is no lengthy wakeup. Sometimes the spinal does not take—which then requires general—or requires extra time to set up even in the best of hands.

“Some anesthesia providers feel the same way and may be more comfortable with general. Efficiency and willingness to do regional is certainly related to the skill of the anesthesia provider.”

This has me thinking that the surgeon and anesthesiologist don’t consider what’s best for the patient in terms of blood clot risk, which includes the DVT becoming a life-threatening pulmonary embolus

Dr. Boucher says, “Regarding DVT/PE, there is research that both supports and refutes lower rates in regional anesthesia. It is true that DVT/PE are major medical complications after knee replacement, but in my opinion the more pertinent risk factors are the patient's comorbidities and post-op immobility rather than type of anesthesia.”


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