Total Joint Protocols & Surgeon Case Guide
Total Hip & Knee Arthroplasty General Guidelines
Please note: the requested anesthesia type booked into EPIC is auto-filled for these surgeries and has little to no meaning. For example, Miller cases will always show “R/M” and Goodman cases will always show “G”. The type of anesthetic you do is up to you and should be appropriate for the case and for the patient needs. This is a rough general guide.Preop Meds - Ordered by surgical team, given in preop holding on day of surgery
Acetaminophen 1g PO. Reduce dose/use caution in liver disease
Celebrex 200 mg PO, caution in renal insufficiency
Gabapentin 600 mg PO (300 mg if age > 70 or GFR < 50; 100 mg for dialysis patient)
Regional Anesthesia - Please see surgeon specific notes below
Intraoperative Anesthesia
Spinal + MAC preferred - please see surgeon specific notes below
Tranexamic acid 1,000mg pre-incision, and another 1,000mg at beginning of closure
Dexamethasone 4-8 mg
Consider ketamine 0.5 mg/kg
Local anesthetic infiltration - a mix of ropivacaine and toradol - done by surgeon in the field
Dr. Miller
Operating time: primary joint in ~ 50 minutes skin to skin
For robotic TKAs - add ~ 20 minutes operating time. Arm on operative side will be crossed over chest
Regional: No block - does own local anesthetic infiltration
Strongly prefers spinal + MAC - especially true for outpatient joints
Recommend 60-70mg mepivacaine spinal (3.0-3.5cc of 2% mepivacaine)
No foley for primary joints
Also works private practice for El Camino Hospital
Dr. Maloney
Operating time: primary joint in ~ 60 minutes skin to skin
For robotic TKA cases add ~ 20 minutes operating time. Arm on operative side will be crossed over chest
Regional: consent for PACU block and confirm with regional team & surgeon
Strongly prefers spinal + MAC - especially true for outpatient joints
Recommend 60-70mg mepivacaine spinal (3.0-3.5cc of 2% mepivacaine)
No foley for primary joints
Chair of the orthopedic surgery department.
Dr. Goodman
Operating time: primary joint in ~ 90 minutes skin to skin
Regional: ACC for both primary and revision knees
General vs Spinal + Deep MAC (strongly dislikes patient movement, talking, recall)
Recommend 10-11mg bupivacaine (2.0-2.2cc 0.5% bupivacaine)
For revision surgery - can discuss extent of revision and appropriateness for spinal vs general
Does not do outpatient joints cases
No foley for primary joints
Wants MAP as low as possible for hip surgery: if the patient cannot tolerate this safely please discuss a safe range to maintain the patient at
Does more complex patients (surgically, medically) on Mondays. Runs two rooms on “Goodman Friday” that stagger their start time. The second room usually rolls back ~ 8:30-8:45 AM.
Dr. Huddleston
Operating time: primary joint in ~ 120 minutes skin to skin
Regional: Adductor canal catheter for both primary and revision knees
Strongly prefers spinal + MAC. If a patient is on the fence about it, he is willing to come and help tip the scales towards spinal - contact him or the fellow he is working with. Especially true for outpatient joints
Outpatient hip/knee: recommend 60-70mg mepivacaine (3.0-3.5cc of 2% mepivacaine)
To be admitted: Recommend 10-11mg bupivacaine (2.0-2.2cc 0.5% bupivacaine)
For revision surgery - can discuss extent of revision and appropriateness for spinal vs general
For outpatient joints likes to give the patient 1-2L intraop, and he will write for an additional bolus in PACU before they DC
Patients that will be admitted get a foley catheter. Outpatients will not.
Chief of the Orthopedic Arthritis Service
Dr. Amanatullah
Operating time: primary joint in ~ 120 minutes skin to skin
Will have regional place ACC for ONLY revision knees
General versus spinal + MAC (leans a bit more towards general - consider spinal when patient has a preference for it or patient would strongly benefit)
Recommend 10-11mg bupivacaine (2.0-2.2cc 0.5% bupivacaine)
No foley for primary joints
Does NOT use tourniquets for knee surgery - results in more intraoperative blood loss. He will ask for the blood pressure to be controlled similar to a hip. For a discussion of why he does this please read this article.
In general, has many more complex and sicker patients
Dr. Hooper
Operating time: primary joint in ~ 90 minutes skin to skin
Regional: single shot adductor canal for TKR
Prefers spinal + MAC - especially true for outpatient joints
Recommend 60-70mg mepivacaine (3.0-3.5cc of 2% mepivacaine) vs 10-11mg bupivacaine (2.0-2.2cc 0.5% bupivacaine)
Does outpatient joint surgery at OSC
No foley for primary joints
Asks her patients to drink a bottle of Ensure Pre-Surgery Clear Carbohydrate Drink on the morning of surgery Please apply the standard 2 hour NPO rules
Joint Revision Surgery
When a joint revision is booked, in EPIC it is simply listed as “Knee/Hip Total Arthroplasty Revision.” Revision joint surgery can be very quick and straightforward, or can be incredibly complex and morbid. It is important to understand exactly what is being done to be able to formulate an appropriate anesthetic plan. Sometimes this information can be gleamed from the surgeon’s clinic note. A good place to look is the “Letters” tab in EPIC. If unsure, please talk to the surgical team to clarify.
Revision Hip
What is the reason for revision? How long ago was the implant placed?
Implant wear/loosening
Infection
Recurrent dislocations
Periprosthetic fracture
Reaction to metal components/allergy
Which components are being replaced?
Cup
Liner
Head
Femoral stem – note that removal of a well-fixed stem is surgically difficult and can involve high levels of blood loss. Buzz words: “Extended trochanteric osteotomy”
Anterior Hip Replacement
Dr. Hooper & Goodnough will sometimes do anterior hip replacements (versus the traditional lateral approach). The anterior approach avoids cutting through major muscles so recovery is usually faster and there is less risk for hip dislocation due to the tissues that naturally keep the hip in place are not disrupted as in a traditional approach. However, the surgery is more technically demanding and may not be ideal for an obese patient.
Operating time: primary joint in 2.0 - 2.5 hours
Can be done as GA or spinal/MAC
The operation is performed on a Hana table pictured to the right. The Hana table allows for traction and rotation of the hip joint during the surgery.
GA or spinal done on patient gurney. After the patient is asleep, traction “ski boots” are placed on the patient and the patient is moved to the Hana table.
The patient is moved down such that their groin is pressed against a post – it is important to make sure there is not excessive pressure
C-arm is used throughout the operation – you will need lead protection
Once the operation is complete, the patient is transferred back to a hospital bed for emergence and extubation. Do not wake the patient up in the traction table as serious injury can occur if the patient attempts to move while still in traction.