Orthopedic Joint Anesthesia Rotation

The objective of the rotation is to train you in the anesthetic techniques for a variety of orthopedic surgical procedures, focusing on total joint replacements and joint revision surgery. At the end of the rotation, you should be capable of selecting and executing an appropriate anesthetic plan that is best given the patient’s comorbidities as well as the anticipated surgical issues. Unique to this MSD rotation, you will have ample opportunity to perform spinal anesthetics.

Attendance at the weekly lecture as well as Monday morning Grand Rounds is expected. It is also the expectation of the department that you will read outside of clinical work independently.

Feedback via a daily debriefing at the end of the workday is expected. At the end of the rotation, the rotation director with input from other faculty will evaluate via MedHub the resident in all 6 core competencies: Medical knowledge, Patient care, Interpersonal communication skills, Professionalism, Practiced based learning and Systems based practice.

Goals and Objectives

1. To develop expertise in neuraxial anesthesia techniques for primary and revision total joint arthroplasty.

2. To understand anesthetic implications for same-day discharge and enhanced recovery protocols.

3. To anticipate and manage the unique physiological and logistical considerations of revision arthroplasty procedures.

4. To coordinate with the surgical team, regional anesthesia, nursing, and consultants to ensure safe and efficient patient care.

5. To understand pharmacologic considerations including intrathecal drug selection and blood-sparing strategies.

Patient Care (PC)

• PC1: Performs comprehensive preoperative evaluations with attention to patient comorbidities, anticoagulation status, airway considerations, and surgical factors. Identifies appropriate candidates for neuraxial anesthesia.

• PC2: Selects and prepares spinal medications based on planned surgical duration and discharge goals, choosing local anesthetics (e.g., bupivacaine, mepivacaine) based on baricity and duration. Understands how drug choice affects block height and resolution.

• PC3: Demonstrates safe and efficient performance of spinal anesthesia with proper positioning, sterile technique, and confirmation of adequate block. Assesses for block effectiveness and anticipates need for intraoperative conversion to general anesthesia if necessary.

• PC4: Coordinates with the regional anesthesia team to ensure timely placement of adductor canal blocks in total knee arthroplasty patients and understands their analgesic benefits.

• PC5: Understands key principles of same-day discharge including early ambulation, opioid-sparing strategies, and spinal recovery time. Plans anesthetics to support early functional recovery.

• PC6: Anticipates the unique needs of revision arthroplasty cases, including increased surgical time, altered anatomy, potential for greater blood loss, and implications for anesthetic selection.

Medical Knowledge (MK)

• MK1: Demonstrates detailed knowledge of spinal anesthesia for joint replacement, including appropriate patient selection, contraindications, physiologic effects, and troubleshooting failed blocks. Understands the pharmacology and selection of intrathecal agents (e.g., bupivacaine, mepivacaine), including baricity, block spread, and expected duration based on surgical needs. Describes the indications and contraindications for neuraxial anesthesia in revision procedures and lengthy cases. Understands how to assess block adequacy and indications for conversion to general anesthesia.

• MK2: Explains the mechanism of action of tranexamic acid (TXA) as an antifibrinolytic agent that inhibits plasminogen activation and stabilizes clot formation. Reviews current literature supporting TXA use in total hip and knee arthroplasty to reduce perioperative blood loss and transfusion requirements. Understands standard dosing protocols and identifies scenarios where TXA should be used with caution. Weighs risks and benefits of TXA use in patients with borderline contraindications and collaborates with surgery and pharmacy when needed.

Systems-Based Practice (SBP)

• SBP1: Collaborates effectively with the surgical team, nursing staff, and regional anesthesia service to optimize workflow and enhance patient safety.

• SBP2: Participates in enhanced recovery protocols and institutional initiatives that support high-quality, same-day discharge arthroplasty care.

Practice-Based Learning and Improvement (PBLI)

• PBLI1: Incorporates feedback to improve spinal anesthesia technique, efficiency, and clinical decision-making across a spectrum of patients.

• PBLI2: Reviews literature and practice guidelines related to arthroplasty anesthesia, including neuraxial technique, TXA use, and ERAS protocols.

Professionalism (P)

• P1: Demonstrates a respectful, patient-centered approach to perioperative care, including preoperative education and shared decision-making.

• P2: Maintains focus and professionalism in high-volume surgical settings requiring timely turnover and consistent clinical performance.

Interpersonal and Communication Skills (ICS)

• ICS1: Communicates clearly with surgical, nursing, and regional teams regarding anesthetic plans, discharge goals, and block coverage.

• ICS2: Provides appropriate handoffs to PACU or ward staff with attention to block status, anesthetic course, intraoperative concerns, and postoperative monitoring needs.