PRINTER-FRIENDLY VERSION AVAILABLE AT ANESTHESIOLOGYNEWS.

COM

Regional Anesthesia for

Total Joint Arthroplasty
DAVID A. PROVENZANO, MD
A

Executive Director
ll

Institute for Pain Diagnostics and Care

rig

Co

Ohio Valley General Hospital

ht

py

McKees Rocks, Pennsylvania

s

rig ed.
re

EUGENE R. VISCUSI, MD
ht
se
rv

Director, Acute Pain Management

20

Department of Anesthesiology
Thomas Jefferson University
12
Re

Philadelphia, Pennsylvania
M
pr

cM
od

Dr. Provenzano has consulted for Janssen Global

uc

Services, LLC, and Medtronic, and received

ah in w

honoraria from Cadence Pharmaceuticals.

tio

on
n

Pu

Dr. Viscusi has received research funding from

AcelRx, Adolor/Cubist, Cumberland, and Salix;
bl

consulted for AcelRx, Cadence, Cubist, Incline,

is
ho

and Pacira; and received honoraria from Cadence

hi

and Merck.
ng
le
or

G
ro
in

up
pa

P
atients undergoing total joint arthroplasty (TJA) experience
un ou
rt
w

high levels of pain after surgery that often interferes with

le
ith

ss

their functional recovery and sleep patterns in the postoperative

ot
he
tp

period.1 In one study, patients undergoing total hip arthroplasty (THA)

rw
er

and total knee arthroplasty (TKA) reported mean worst pain severities of
is
m

e
is

7.6 and 8.1 on a 10-point scale, respectively.1 Numerous techniques have

no
si
on

te

been developed for anesthesia and analgesia in an effort to optimize

d.
is
pr

perioperative pain control, patient satisfaction, and functional recovery.

oh

Because clinician preference strongly influences patient selection and

ib
ite

decision making, anesthesiologists and orthopedic surgeons must

d.

understand the current literature and level of evidence for each technique.2
This article provides an updated review of the evidence for regional
anesthesia for TJA surgery with an emphasis on the risks and benefits of
each technique for intraoperative anesthesia and postoperative analgesia.

I N D E P E N D E N T LY D E V E L O P E D B Y M C M A H O N P U B L I S H I N G A N E ST H E S I O LO GY N E WS S P E C I A L E D I T I O N • O C TO B E R 2 0 1 2 59
 (DVT) and pulmonary embolism (PE).3 It is important to
Table 1. Methods of Postoperative note that many of the studies in this review that favored
Pain Control for Total Joint regional anesthesia over general anesthesia in the reduc-
Arthroplasty tion of vascular events were earlier trials that examined
individuals who were not receiving anticoagulation pro-
phylaxis. A review of general and regional anesthesia
Intravenous opioids (IV-PCA)
for THA that contained research from 1966 to August
Oral opioids 2005, suggested that neuraxial block decreased the inci-
dence of radiographically diagnosed DVT and PE, and
Nonopioid analgesics decreased operative time by 7.1 minutes and intraopera-
tive blood loss by 275 mL.4
Neuraxial anesthesia and analgesia
A

Contemporary reviews that examined only papers

ll

• Spinal–intrathecal opioids from 1990 onward have provided evidence for improve-
rig

Co

ment in pain control but do not always demonstrate

ht

py

• Epidural–continuous infusion improvements in cardiovascular outcomes and mortal-

s

rig ed.

ity. One systematic review of studies published since

re

• Epidural–single-injection EREM
1990 found insufficient evidence from randomized con-
ht
se

trolled trials to conclude that anesthetic technique

rv

Single and continuous peripheral nerve blocks

©

affected mortality, cardiovascular morbidity or inci-

20

• Femoral nerve block dence of DVT and PE in patients undergoing THA.5

12
Re

In addition, regional anesthesia did not reduce hospi-

• Sciatic nerve block
M
pr

tal length of stay or facilitate rehabilitation. In 2009, a

cM
od

• Lumbar plexus block systematic review that examined contemporary litera-

ture on randomized controlled trials of TKA published
uc

ah in w

EREM, extended-release epidural morphine; since 1990 found insufficient evidence to conclude that
tio

on

PCA, patient-controlled analgesia

anesthesia technique influenced mortality, cardiovascu-
n

Pu

lar morbidity, or incidence of DVT and PE when using

bl

thromboprophylaxis.6
is

TJA is performed with either a primary regional or Anesthetic choice also has been shown to affect
ho

hi

general anesthetic technique. Many methods exist for other important outcomes, in addition to pain control,
ng
le

continued perioperative pain control (Table 1). In some including rates of surgical site infection (SSI) and med-
or

cases, various modalities will be combined in an effort ical costs. In a retrospective review of more than 3,000
ro
in

to optimize pain management. Each method for pain knee or hip arthroplasty surgeries, Chang and col-
up
pa

control is associated with specific benefits, risks, side leagues, demonstrated a significant reduction in 30-day
un ou

effects, economic implications, patient satisfaction lev- SSI rates—1.2% for epidural or spinal anesthesia versus
rt

els, and labor requirements for the health care team. 2.8% for general anesthesia.7 The odds of an SSI occur-
w

le
ith

ss

ring in a patient receiving general anesthesia were 2.2

General Versus Regional Anesthesia for Total times greater than when neuraxial anesthesia was used.
ot

Joint Arthroplasty Proposed mechanisms for possible reduction in surgical

he
tp

Several advantages have been suggested for the use site infections with neuraxial anesthesia include modu-
rw
er

of neuraxial anesthesia for TJA surgery. These include lation of the inflammatory response, vasodilation and
is
m

modification of the hypercoagulable surgical state, improvement in tissue oxygenation, and improvements
e
is

improvements in regional blood flow, improvement in in postoperative analgesia.8

no
si
on

pain control, and reduction in the surgical neuroendo- Spinal anesthesia has been shown to be more cost-
te

crine stress response (Table 2). From the surgeon’s per- effective for TJA. Gonano and colleagues randomized
d.
is

spective, spinal anesthesia also provides ideal operating 40 patients to receive either spinal anesthesia or gen-
pr

conditions—profound muscle relaxation—moderate eral anesthesia and examined the costs of drugs and
oh

hypotension, which reduces blood loss, and the poten- supplies for both the chosen anesthetic and associated
ib

tial for faster room turnover. recovery.9 They found that spinal anesthesia was asso-
ite

Recent systematic reviews have examined the influ- ciated with lower fixed and variable costs, resulting in
d.

ence of the anesthetic choice for TJA surgery on out-
comes. Reviews that included dates from 1966 onward
suggest that neuraxial anesthesia improves specific end-
organ outcomes and postoperative pain control. In a
meta-analysis specifically examining neuraxial regional
anesthesia for TJA, regional anesthesia was associated
with significant reductions in operating time, need for
transfusions, nausea and vomiting, and incidence of
thromboembolic disease including deep vein thrombosis
a 48% savings (excluding expenditures for personnel)
compared with general anesthesia.
Regional Techniques for Postoperative
Analgesia for Total Joint Arthroplasty
Several analgesic techniques exist for postoperative
pain management for TJA surgery. Each regional anes-
thetic technique has specific advantages and disadvan-
tages. Selection of the appropriate technique is best

60 I N D E P E N D E N T LY D E V E L O P E D B Y M C M A H O N P U B L I S H I N G
guided through an understanding of the associated
risk–benefit profile of each technique and the pain man- Table 2. Physiologic Sequelae of the
agement needs for the specific clinical situation. Neuroendocrine Stress Response
INTRATHECAL OPIOIDS Hyperactivity of the autonomic nervous system
One analgesic approach that requires only minor
modifications in the anesthetic plan is the addition of Increased cardiovascular stress
intrathecal opioids to the spinal injection of local anes- Dysfunction in respiratory mechanics
thetic. Typically, intrathecal morphine will be added in a
dose range from 0.2 to 0.3 mg. For THA and TKA, intra- Decreased muscle protein synthesis
thecal morphine has been shown to improve patient
Elevated metabolic rate with an associated pro-
A

satisfaction compared with IV patient-controlled anal- tein catabolic state

ll

gesia (IV-PCA) with opioids. However, intrathecal mor-

rig

Co

phine only reduced the supplemental postoperative Increased formation of blood clots
ht

py

PCA morphine requirements for the patients undergo-

s

Slower return of bowel function

rig ed.

ing THA.10
re

When intrathecal opioids are administered, additional

ht

Impaired immune function

se

forms of pain control are needed to control “break-

rv

through pain” and for pain that outlasts the duration

20

of the therapy. Respiratory monitoring also is required

12
Re

when intrathecal opioids are administered. associated with a lower incidence of side effects, includ-
M
pr

ing nausea and vomiting, urinary retention, and arte-

EPIDURAL ANALGESIA
cM
od

rial hypotension. Single and continuous lumbar plexus

Epidural analgesia with a single injection of extended- blocks also have been employed for postoperative
uc

ah in w

release epidural morphine (EREM) or continuous epi- analgesia. A lumbar plexus block is performed with the
tio

on

dural infusions with local anesthetics can be effective goal of anesthetizing additional nerve branches (lateral
n

Pu

methods of pain control in patients undergoing joint femoral cutaneous, femoral, and obturator nerves) that
bl

surgery. When specifically examining the use of epidur- innervate the surgical area. A continuous lumbar plexus
is

als for TJA compared with IV-PCA, epidural analgesia block was found to be superior to IV-PCA for pain man-
ho

hi

has been shown in high-quality studies to improve pain agement, with a reduction in morphine consumption,
ng
le

relief and recovery time.11,12 A Cochrane Collaboration improvement in pain control, and patient satisfaction.18
or

review demonstrated that epidural analgesia for pain Although the lumbar plexus nerve block provides
ro
in

relief following TJA in comparison to systemic analge- effective analgesia, recently published guidelines from
up
pa

sia was beneficial, but its effects may be limited only to the American Society of Regional Anesthesia and Pain
the early postoperative period, 4 to 6 hours.13
un ou

Medicine for patients receiving antithrombotic therapy

rt

Use of EREM has been studied in patients undergo- circumscribe its use.19 The new guidelines state that the
w

le
ith

ss

ing TKA and THA. Compared with IV-PCA, the patients same precautions should be applied to deep periph-
treated with EREM for TKA required significantly less eral nerve catheters as neuraxial techniques. Alterna-
ot

postoperative opioids and had reduced mean pain tives to the lumbar plexus block have been investigated,
he
tp

intensity recall scores.14 For THA surgery, EREM demon- including a continuous femoral nerve block (CFNB). In
rw
er

strated improved pain control at rest to 48 hours post- one study, Ilfeld and colleagues compared a continuous
is
m

dose and improvement in pain control ratings15; 25% of posterior lumbar plexus nerve block with a CFNB.20 The
e
is

THA patients who received EREM did not require sup- femoral nerve-stimulating catheter was advanced up to
no
si
on

plemental analgesia. 15 cm beyond the tip with the goal of obtaining cov-
te

erage of the obturator and lateral femoral cutaneous

d.
is

Regional Techniques for Postoperative nerves. Pain control was equivalent for these 2 meth-
pr

Analgesia for Total Hip Arthroplasty ods. The CFNB was associated with shorter ambulation
oh

THA is associated with a high level of postopera- distances the morning after surgery, suggesting greater
ib

tive pain, although perhaps less than TKA. Many tech- impairment in the quadriceps femoris muscle.
ite

niques for administering regional anesthesia have been

d.

explored for THA to improve pain control.16 These
include neuraxial analgesia, peripheral nerve blocks
(PMBs), and EREM. Singelyn and colleagues compared
IV-PCA with morphine, continuous epidural analgesia,
and continuous femoral nerve sheath block for post-
operative analgesia in THA.17 The authors found no
difference in quality of pain relief, postoperative hip
rehabilitation, and duration of hospital stay for any of
these approaches. The continuous femoral block was
Regional Anesthesia for Total Knee
Arthroplasty
PERIPHERAL NERVE BLOCKS
PNBs, including single-injection and continuous PNB
catheters (CPNBC), have received substantial atten-
tion as alternatives to neuraxial analgesia and systemic
opioids for TKA. Some of the emphasis on PNBs arises
from concerns about concurrent anticoagulation and

A N E ST H E S I O LO GY N E WS S P E C I A L E D I T I O N • O C TO B E R 2 0 1 2 61
 Although a femoral block does improve postopera-
tive pain control for TKA, 60% to 80% of patients still
will complain of clinically significant pain. In an attempt
to improve pain control, single and continuous sciatic
nerve blocks can be administered. Evidence is mixed
for the analgesic benefits of adding a single-injection
or continuous catheter sciatic nerve block to a femoral
nerve block technique. In addition, no consensus has
been reached on whether a sciatic nerve block should
be performed for all TKA cases in which a femoral nerve
block also is performed.23 Neither a single-injection nor
A

a continuous catheter sciatic nerve block is without the-

ll

oretical risks and possible disadvantages, including the

rig

Co

prevention of the early detection of compartment syn-

ht

py

drome or neurologic injury resulting from surgery and

s

rig ed.

the further impairment of motor function, thus imped-

re

ing physical therapy during its duration of action. Some

ht
se

of the hesitation to perform sciatic nerve blocks is

rv

related to the risk profile of the procedure and the sur-

20

gical vulnerability of the nerve. Sciatic nerve injury after

12
Re

TKA, not related to regional anesthetic technique, is a

M
pr

known complication.
cM
od

Figure. An ultrasound-guided right- Two randomized controlled trials24,25 and a recent

systematic review26 have attempted to address whether
uc

ah in w

sided femoral nerve block. The red

blocking the sciatic nerve is advantageous for post-
tio

on

arrows delineate the placed needle. operative pain control and other related clinical out-
n

The triangle-shaped femoral nerve is

Pu

comes following TKA. In one trial, patients undergoing

lateral to the femoral artery (FA).
bl

TKA were randomized to 1 of 3 groups: a femoral nerve

is

catheter, a femoral catheter combined with a single

ho

hi

injection, or a femoral catheter plus a continuous sci-

ng
le

atic nerve block.25 The addition of a single-injection

or

neuraxial anesthesia. The employment of low-molecu- sciatic nerve block to the CFNB reduced postopera-
ro
in

lar-weight heparin for DVT prophylaxis has limited the tive pain on the day of surgery. The continuous sciatic
up
pa

use of epidurals for postoperative analgesia. Although nerve block reduced moderate pain during mobilization
un ou

CPNBCs have been advocated as a means of prolong- on the first 2 postoperative days. A sciatic nerve block
rt

ing the duration of action of single-injection nerve did not influence time to discharge readiness. In a sec-
w

le
ith

ss

blocks, debate still continues on their advantages and ond study, Pham Dang and colleagues demonstrated
disadvantages compared with single-injection blocks. improvements in pain control with a continuous sciatic
ot

nerve block during the first 36 postoperative hours.24

he
tp

FEMORAL AND SCIATIC NERVE BLOCKS A recent systematic review, examining 4 interme-
rw
er

The most commonly used PNBs for TKA are femo- diate-quality randomized and 3 observational studies,
is
m

ral and sciatic (Figure). In 2010, Paul et al performed a established that there is inadequate evidence to define
e
is

meta-analysis of randomized controlled trials that com- the role of adding a sciatic nerve block, and could not
no
si
on

pared a femoral block with or without a sciatic nerve demonstrate a benefit in analgesia beyond 24 hours.26
te

block with PCA or epidural analgesia.21 Compared with Unlike a CFNB, continuous sciatic nerve blocks have
d.
is

PCA alone, a femoral block reduced morphine con- not been shown to improve functional outcomes or
pr

sumption at 24 and 48 hours, pain scores with activity decrease time until discharge readiness.23,25
oh

(but not at rest) at 24 and 48 hours, and the incidence With the current level of evidence for a sciatic nerve
ib

of nausea. No further improvements were found with block, one method to determine its implementation
ite

the addition of a CFNB. Although the femoral nerve could be to observe the patient during early recovery
d.

does not innervate the posterior portion of the knee, in
this meta-analysis a single-jnjection sciatic nerve block
did not offer a pain control advantage.
In a recent trial comparing a single-injection femo-
ral block to CFNB for TKA, pain-intensity ratings were
improved during the first and second days after sur-
gery.22 Opioid consumption and pain-intensity ratings
during physical therapy also were significantly lower
with a CFNB.
to see if he or she is experiencing significant pain from
the posterior aspect of the knee that is not relieved by
the femoral nerve block. If so, the analgesia could be
augmented with a single-injection sciatic nerve block.
Complications
Other factors that must be incorporated into deci-
sion making for the anesthetic and analgesic technique
for TJA include complications and adverse events. All

62 I N D E P E N D E N T LY D E V E L O P E D B Y M C M A H O N P U B L I S H I N G
the regional anesthetic techniques described above
have the following risks, including but not limited to Table 3. Complications/Adverse
bleeding, nerve damage, vascular injury, block failure, Events Associated With CPNBCs and
and infection. Neuraxial techniques and deep peripheral Time Frame of Occurrence
nerve catheters have been associated with devastating
bleeding complications. When opioids are incorporated

Insertion

Removal
Infusion
into neuraxial anesthesia, respiratory depression may
occur. Other opioid-related side effects also may result,
including sedation, pruritus, urinary retention, and post-
operative nausea and vomiting.27 The risks and compli- Neurologic injury Xa X X
cations specifically associated with CPNBCs are shown
A

in Table 3. Vascular injury X X

ll

Although bacterial colonization may be common

rig

Co

Local anesthetic toxicity X X

with certain catheters, the overall risk for infection is
ht

py

low. In one study, the incidence of bacterial colonization Migration/dislodgment X

s

rig ed.

for femoral catheters was reported to be as high as 57%

re

Infection X X X
when catheters were removed at 48 hours.28 Although
ht
se

3 cases of transitory bacteremia likely related to the

rv

Catheter knotting X X
©

femoral catheters were reported, no patients developed

20

an abscess or cellulitis. Catheter retention X

12
Re

Abscesses, cellulitis, and transient bacteremia have Secondary block failure X

M
pr

been reported with CPNBCs. The presence of diabetes

cM

Muscle weaknessb
od

mellitus may increase the risk for infection. Appropri- X

ate steps to reduce the risk for infection include lim-
uc

ah in w

a
X denotes most likely time frame of occurrence or
iting the duration of catheter use and following strict
tio

on

presentation.
aseptic guidelines. Another potential hazard of CPN-
n

b
Muscle weakness may put patients at risk for falls or delay
Pu

BCs that has received significant recent attention is physical therapy after a knee or hip arthroplasty.
bl

the association between lower-extremity blocks and CPNBCs, continuous peripheral nerve blocks
is

patient falls.29-31 Continuous PNBs are associated with

ho

hi

muscle weakness that may lead to falls or that can delay

ng
le

rehabilitation. Lower-extremity nerve blocks have been

or

shown to impair the maintenance of limb stiffness, alter selection of perioperative pain treatment based on effi-
ro
in

proprioception, and decrease lateral stability.32 Post- cacy, safety, and patient satisfaction. The economic
up
pa

operative protocols should be in place to safely and implications and labor requirements of each technique
un ou

appropriately manage quadriceps weakness associated also should be further explored.

rt

with femoral nerve blocks in the postoperative period.

w

le

References
ith

ss

In addition, the selected postoperative pain manage-

ment technique should be tailored to allow for early 1. Strassels SA, Chen C, Carr DB. Postoperative analgesia: economics,
ot

rehabilitation following TJA. Early intensive rehabili- resource use, and patient satisfaction in an urban teaching hospi-
he
tp

tal. Anesth Analg. 2002;94(1):130-137.

tation following TKA (ie, starting rehabilitation within
rw
er

2. Webster F, Bremner S, McCartney CJ. Patient experiences as

24 hours) has been shown to improve muscle strength, knowledge for the evidence base: a qualitative approach to
is
m

range of motion, and pain by the time of discharge from

e

understanding patient experiences regarding the use of regional

is

the hospital.33 anesthesia for hip and knee arthroplasty. Reg Anesth Pain Med.
no
si

2011;36(5):461-465.
on

te

Conclusion 3. Hu S, Zhang ZY, Hua YQ, Li J, Cai ZD. A comparison of regional

d.
is

and general anaesthesia for total replacement of the hip or knee:

TJA is associated with significant levels of postop-
pr

a meta-analysis. J Bone Joint Surg Br. 2009;91(7):935-942.

erative pain. An appropriately selected anesthetic and
oh

4. Mauermann WJ, Shilling AM, Zuo Z: A comparison of neuraxial

analgesic plan will positively influence pain levels and block versus general anesthesia for elective total hip replacement:
ib

function after the procedure. To obtain optimal results a meta-analysis. Anesth Analg. 2006;103(4):1018-1025.
ite

with regional anesthetic and analgesic techniques, 5. Macfarlane AJ, Prasad GA, Chan VW, Brull R. Does regional anaes-
d.

these therapies should comprise one facet of a multi-
modal perioperative treatment plan that includes non-
opioid analgesics and the inclusion of a structured
rehabilitation program. A massive increase in the num-
ber of patients undergoing TJA surgery in the United
States is expected to occur over the next 2 decades;
by 2030, it is estimated that nearly 3.5 million primary
TKA surgeries alone will be performed in this coun-
try.34 Research must continue to define and refine the
thesia improve outcome after total hip arthroplasty? A systematic
review. Br J Anaesth. 2009;103(3):335-345.
6. Macfarlane AJ, Prasad GA, Chan VW, Brull R. Does regional anes-
thesia improve outcome after total knee arthroplasty? Clin Orthop
Relat Res. 2009;467(9):2379-2402.
7. Chang CC, Lin HC, Lin HW, Lin HC. Anesthetic management and
surgical site infections in total hip or knee replacement: a popula-
tion-based study. Anesthesiology. 2010;113(2):279-284.
8. Sessler DI. Neuraxial anesthesia and surgical site infection.
Anesthesiology. 2010;113(2):265-267.

A N E ST H E S I O LO GY N E WS S P E C I A L E D I T I O N • O C TO B E R 2 0 1 2 63
9. Gonano C, Leitgeb U, Sitzwohl C, Ihra G, Weinstabl C, Kettner SC.
Spinal versus general anesthesia for orthopedic surgery: anesthe-
sia drug and supply costs. Anesth Analg. 2006;102(2):524-529.
10. Rathmell JP, Pino CA, Taylor R, Patrin T, Viani BA. Intrathecal mor-
phine for postoperative analgesia: a randomized, controlled,
dose-ranging study after hip and knee arthroplasty. Anesth Analg.
2003;97(5):1452-1457.
11. Singelyn FJ, Deyaert M, Joris D, Pendeville E, Gouverneur JM.
Effects of intravenous patient-controlled analgesia with morphine,
continuous epidural analgesia, and continuous three-in-one block
on postoperative pain and knee rehabilitation after unilateral total
knee arthroplasty. Anesth Analg. 1998;87(1):88-92.
12. Capdevila X, Barthelet Y, Biboulet P, Ryckwaert Y, Rubenovitch J,
d’Athis F. Effects of perioperative analgesic technique on the sur-
A
meta-analysis of randomized controlled trials. Anesthesiology.
2010;113(5):1144-1162.
22. Salinas FV, Liu SS, Mulroy MF. The effect of single-injection femoral
nerve block versus continuous femoral nerve block after total knee
arthroplasty on hospital length of stay and long-term functional
recovery within an established clinical pathway. Anesth Analg.
2006;102(4):1234-1239.
23. Ilfeld BM, Madison SJ. The sciatic nerve and knee arthroplasty: to
block, or not to block—that is the question. Reg Anesth Pain Med.
2011;36(5):421-423.
24. Pham Dang C, Gautheron E, Guilley J, et al. The value of adding
sciatic block to continuous femoral block for analgesia after total
knee replacement. Reg Anesth Pain Med. 2005;30(2):128-133.

gical outcome and duration of rehabilitation after major knee

ll

25. Wegener JT, van Ooij B, van Dijk CN, Hollmann MW, Preckel B,
surgery. Anesthesiology. 1999;91(1):8-15.
rig

Stevens MF. Value of single-injection or continuous sciatic nerve

Co

13. Choi PT, Bhandari M, Scott J, Douketis J. Epidural analgesia for block in addition to a continuous femoral nerve block in patients
ht

py

pain relief following hip or knee replacement. Cochrane Database undergoing total knee arthroplasty: a prospective, randomized,
s

Syst Rev. 2003;(3):CD003071. controlled trial. Reg Anesth Pain Med. 2011;36(5):481-488.
rig ed.
re

14. Hartrick CT, Martin G, Kantor G, Koncelik J, Manvelian G. Eval- 26. Abdallah FW, Brull R. Is sciatic nerve block advantageous when
ht
se

uation of a single-dose, extended-release epidural morphine combined with femoral nerve block for postoperative analgesia
rv

formulation for pain after knee arthroplasty. J Bone Joint Surg Am. following total knee arthroplasty?: a systematic review. Reg Anesth
2006;88(2):273-281. Pain Med. 2011;36(5):493-498.
20

15. Viscusi ER, Martin G, Hartrick CT, Singla N, Manvelian G, EREM 27. Neal JM, Rathmell JP. Complications in Regional Anesthesia & Pain
12
Re

Study Group. Forty-eight hours of postoperative pain relief after Medicine. Philadelphia, PA: Saunders Elsevier; 2007.
total hip arthroplasty with a novel, extended-release epidural
M
pr

morphine formulation. Anesthesiology. 2005;102(5):1014-1022. 28. Cuvillon P, Ripart J, Lalourcey L, et al. The continuous femoral
cM
od

nerve block catheter for postoperative analgesia: bacterial col-

16. Indelli PF, Grant SA, Nielsen K, Vail TP. Regional anesthesia in hip onization, infectious rate and adverse effects. Anesth Analg.
uc

ah in w

surgery. Clin Orthop Relat Res. 2005;441:250-255. 2001;93(4):1045-1049.

tio

on

17. Singelyn FJ, Ferrant T, Malisse MF, Joris D. Effects of intravenous

29. Ilfeld BM, Duke KB, Donohue MC. The association between lower
n

patient-controlled analgesia with morphine, continuous epidural

extremity continuous peripheral nerve blocks and patient falls after
Pu

analgesia, and continuous femoral nerve sheath block on rehabili-

knee and hip arthroplasty. Anesth Analg. 2010;111(6):1552-1554.
tation after unilateral total-hip arthroplasty. Reg Anesth Pain Med.
bl

2005;30(5):452-457. 30. Kandasami M, Kinninmonth AW, Sarungi M, Baines J, Scott NB.

is
ho

hi

18. Siddiqui ZI, Cepeda MS, Denman W, Schumann R, Carr DB. Con- Femoral nerve block for total knee replacement—a word of cau-
tion. Knee. 2009;16(2):98-100.
ng
le

tinuous lumbar plexus block provides improved analgesia with

fewer side effects compared with systemic opioids after hip
or

31. Sharma S, Iorio R, Specht LM, Davies-Lepie S, Healy WL.

G

arthroplasty: a randomized controlled trial. Reg Anesth Pain Med.

Complications of femoral nerve block for total knee arthroplasty.
ro

2007;32(5):393-398.
in

Clin Orthop Relat Res. 2010;468(1):135-140.

up

19. Horlocker TT, Wedel DJ, Rowlingson JC, et al. Regional anesthe-
pa

sia in the patient receiving antithrombotic or thrombolytic therapy: 32. Muraskin SI, Conrad B, Zheng N, Morey TE, Enneking FK. Falls
un ou
rt

American Society of Regional Anesthesia and Pain Medicine Evi- associated with lower-extremity-nerve blocks: a pilot investigation
dence-Based Guidelines (Third Edition). Reg Anesth Pain Med. of mechanisms. Reg Anesth Pain Med. 2007;32(1):67-72.
w

le

2010;35(1):64-101.
ith

ss

33. Labraca NS, Castro-Sánchez AM, Matarán-Peñarrocha GA, Arroyo-

20. Ilfeld BM, Mariano ER, Madison SJ, et al. Continuous femoral ver- Morales M, Sánchez-Joya Mdel M, Moreno-Lorenzo C. Benefits of
ot

sus posterior lumbar plexus nerve blocks for analgesia after starting rehabilitation within 24 hours of primary total knee arthro-
he

plasty: randomized clinical trial. Clin Rehabil. 2011;25(6):557-566.

tp

hip arthroplasty: a randomized, controlled study. Anesth Analg.

2011;113(4):897-903.
rw

34. Kurtz S, Ong K, Lau E, Mowat F, Halpern M. Projections of primary

er

21. Paul JE, Arya A, Hurlburt L, et al. Femoral nerve block and revision hip and knee arthroplasty in the United States from
is
m

improves analgesia outcomes after total knee arthroplasty: a 2005 to 2030. J Bone Joint Surg Am. 2007;89(4):780-785.
e
is

no
si
on

te
d.
is
pr
oh
ib
ite
d.

64 I N D E P E N D E N T LY D E V E L O P E D B Y M C M A H O N P U B L I S H I N G