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NB: This is a relatively new technique but it is getting increasingly popular. We asked a very experienced practitioner to describe his “recipe.” Keep in mind that success seems to be surgeon-dependent.

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  • Early mobilization reduces both the incidence of DVT and PE, and the hospital LOS
  • Pain is only one of a number of issues that prevent a patient getting out of bed in the early postoperative period. Other factors include patient personality, motivation, fear, staff attitudes, hypotension, motor block, stiffness, dizziness, PONV, surgical morbidity, etc
  • Complete analgesia is no longer necessary or desirable for lower limb arthroplasty. Preoperative conditioning and the combination of an intraoperative spinal with intra-articular catheters appears to provide the “ideal” balance between good analgesia and the ability to mobilize early for these procedures
  • Avoiding perioperative systemic and intrathecal opioids via multimodal nonopioid analgesia (MMA) reduces the incidence of urine retention and PONV
  • Wound infiltration alone without a postoperative wound catheter appears to be all that is required for THA, while a postoperative catheter for 24–48 hours is needed for TKA
  • In an ongoing prospective series beginning in January 2007 of over 7,000 patients undergoing THA and TKA using wound infiltration in an enhanced recovery program in Scotland, the success rate for the technique is 94%. A total of 96% of patients can be mobilized within 24 hours of surgery with median pain scores less than 3. Postoperative IV fluids are only required in 5% of patients and only 7% require urinary catheterization. The median PONV score is zero and median postoperative stay has been reduced from 6.5 to 3.7 days. Notably, joint infection remains low at 0.9% and the need for blood transfusion is very low—2% for THR and 0.6% for TKR compared with the national (UK) average of 20%

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  • Assessment in outpatient clinic:
    • Within 2 weeks of planned day of surgery
    • Multidisciplinary approach from all perioperative specialties
    • Patient education regarding: pain, mobilization, rehabilitation, etc
    • Target a realistic day for discharge based on local data
    • Address individual expectations, hopes, and fears
    • Ensure Hb level >12 g/L. If Hb level <12 g/L, initiate appropriate treatment (iron, folate, EPO) and postpone surgery if needed
    • Optimize comorbidities, especially cardiovascular disease and hypertension
  • On admission:
    • Liberal oral fluids ± hypocaloric drinks up to 2 hours before surgery
  • Premedication:
    • Avoid strong sedatives that delay getting out of bed
    • Multimodal analgesia:
      • Dexamethasone 0.1–0.2 mg/kg orally:
        • Antiemetic and analgesic
        • No problems of wound healing or infection with short course
      • Gabapentin 600 mg orally
      • Oxycontin 10 mg orally
      • Acetaminophen 1 g orally
      • Ibuprofen 400 mg orally

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  • 2.5–5 g IV tranexamic acid before incision
  • Low-dose spinal anesthesia:
    • For example, 6–7.5 mg levobupivacaine or bupivacaine
    • Advantages:
      • No need for full GA—only sedation required; see below
      • Avoids systemic opioids in early postoperative period
      • Reduced blood loss
      • Reduced thromboembolism
      • Reduced PONV
      • Reduced surgical site infection
    • A unilateral spinal anesthetic (USA) can be achieved by having patient lying on side with operating side up, that is, in same position as for surgery. Adding ...

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