Total Hip & Knee Arthroplasty General Guidelines

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 9-11mg bupivacaine (1.8-2.2cc 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

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 9-10mg bupivacaine (1.8-2.0cc 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

• No foley for primary joints

• 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 (anesthesiologist preference)

  • Recommend 9-10mg bupivacaine (1.8-2.0cc 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)

    • For anterior hip surgery recommend 9-10mg bupivacaine (1.8-2.0cc of 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

Dr. Lipof

• Operating time: primary joint in ~ 60 minutes skin to skin

• Regional: single shot adductor canal for TKA

• Prefers spinal + MAC - especially true for outpatient joints

  • • Recommend 60-70mg mepivacaine (3.0-3.5cc of 2% mepivacaine) for any primary joint - including anterior hip replacement

• No foley for primary joints

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?

  • 1. Implant wear/loosening

    2. Infection

    3. Recurrent dislocations

    4. Periprosthetic fracture

    5. Reaction to metal components/allergy

• Which components are being replaced?

  • 1. Cup

    2. Liner

    3. Head

    4. 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”