Background: Long-term and sustainable clinical practice changes in anesthesia procedures have not previously been reported. Therefore, we performed a 5-year audit following implementation of a clinical pathway change favoring spinal anesthesia for total knee arthroplasty (TKA). We similarly evaluated a parallel cohort of patients undergoing total hip arthroplasty (THA), who did not undergo a clinical pathway change, and studied utilization rates of continuous peripheral nerve block (CPNB). Methods: We identified all primary unilateral TKA and THA cases completed from January 2013 through December 2018, thereby including clinical pathway change data from one-year pre-implementation to 5-years post-implementation. Our primary outcome was the overall application rate of spinal anesthesia. Secondary outcomes included CPNB utilization rate, 30-day postoperative complications, and resource utilization variables such as hospital readmission, emergency department visits, and blood transfusions. Results: The sample included 1,859 cases, consisting of 1,250 TKAs and 609 THAs. During the initial year post-implementation, 174/221 (78.7%) TKAs received spinal anesthesia compared to 23/186 (12.4%) cases the year before implementation (P < 0.001). During the following 4-year period, 647/843 (77.2%) TKAs received spinal anesthesia (P = 0.532 vs. year 1). The number of THA cases receiving spinal anesthesia the year after implementation was 78/124 (62.9%), compared to 48/116 (41.4%) pre-implementation (P = 0.001); however, the rate decreased over the following 4-year period to 193/369 (52.3%) (P = 0.040 vs. year 1). CPNB use was high in both groups, and there were no differences in 30-day postoperative complications, hospital readmission, emergency department visits, or blood transfusions. Conclusions A clinical pathway change promoting spinal anesthesia for TKA can be effectively implemented and sustained over a 5-year period.

BACKGROUND: Adductor canal catheters offer advantages over femoral nerve catheters for knee replacement patients because they produce less quadriceps muscle weakness; however, applying adductor canal catheters in bedside clinical practice remains challenging. There is currently no patient-reported outcome that accurately predicts patients' physical function after knee replacement. The present study evaluates the validity of a relatively new patient-reported outcome, i.e., a numbness score obtained using a numeric rating scale, and assesses its predictive value on postoperative ambulation. METHODS: We conducted a retrospective cohort study pooling data from two previously-published clinical trials using identical research methodologies. Both studies recruited patients undergoing knee replacement; one studied adductor canal catheters while the other studied femoral nerve catheters. Our primary outcome was patient-reported numbness scores on postoperative day 1. We also examined postoperative day 1 ambulation distance and its association with postoperative numbness using linear regression, adjusting for age, body mass index, and physical status. RESULTS: Data from 94 subjects were included (femoral subjects, n = 46; adductor canal subjects, n = 48). Adductor canal patients reported decreased numbness (median [10th-90th percentiles]) compared to femoral patients (0 [0-5] vs. 4 [0-10], P = 0.001). Adductor canal patients also ambulated seven times further on postoperative day 1 relative to femoral patients. There was a significant association between postoperative day 1 total ambulation distance and numbness (Beta = -2.6; 95% CI: -4.5, -0.8, P = 0.01) with R2 = 0.1. CONCLUSIONS: Adductor canal catheters facilitate improved early ambulation and produce less patient-reported numbness after knee replacement, but the correlation between these two variables is weak.
Arthroplasty* ; Body Mass Index ; Catheters* ; Cohort Studies ; Early Ambulation ; Femoral Nerve ; Humans ; Hypesthesia* ; Knee* ; Linear Models ; Nerve Block* ; Quadriceps Muscle ; Retrospective Studies ; Walking*

BACKGROUND: Both neuraxial and peripheral regional analgesic techniques offer postoperative analgesia for total hip arthroplasty (THA) patients. While no single technique is preferred, quadriceps muscle weakness from peripheral nerve blocks may impede rehabilitation. We designed this study to compare postoperative ambulation outcome in THA patients who were treated with a new ultrasound-guided fascia iliaca catheter (FIC) technique or intrathecal morphine (ITM). METHODS: We reviewed the electronic health records of a sequential series of primary unilateral THA patients who were part of a standardized clinical pathway; apart from differences in regional analgesic technique, all other aspects of the pathway were the same. Our primary outcome was total ambulation distance (meters) combined for postoperative days 1 and 2. Secondary outcomes included daily opioid consumption (morphine milligram equivalents) and analgesic-related side effects. We examined the association between the primary outcome and analgesic technique by performing crude and adjusted ordinary least-squares linear regression. A P value < 0.05 was considered statistically-significant. RESULTS: The study analyzed the records of 179 patients (fascia iliaca, n = 106; intrathecal, n = 73). The primary outcome (total ambulation distance) did not differ between the groups (P = 0.08). Body mass index (BMI) was the only factor (β = -1.7 [95% CI -0.5 to -2.9], P < 0.01) associated with ambulation distance. Opioid consumption did not differ, while increased pruritus was seen in the intrathecal group (P < 0.01). CONCLUSIONS: BMI affects postoperative ambulation outcome after hip arthroplasty, whereas the type of regional analgesic technique used does not. An ultrasound-guided FIC technique offers similar analgesia with fewer side effects when compared with ITM.
Analgesia ; Anesthesia, Conduction ; Anesthesia, Spinal ; Arthroplasty ; Arthroplasty, Replacement, Hip* ; Body Mass Index ; Catheters* ; Critical Pathways* ; Electronic Health Records ; Fascia* ; Hip ; Humans ; Linear Models ; Morphine ; Nerve Block ; Peripheral Nerves ; Pruritus ; Quadriceps Muscle ; Rehabilitation ; Ultrasonography ; Walking