Research Article

Does Total Intravenous Anesthesia

With Short-acting Spinal Anesthetics
in Primary Hip and Knee Arthroplasty
Facilitate Early Hospital Discharge?

Abstract
Downloaded from https://journals.lww.com/jaaos by BhDMf5ePHKav1zEoum1tQfN4a+kJLhEZgbsIHo4XMi0hCywCX1AWnYQp/IlQrHD3Gamkn0m7hy6RQdEwn41RO+bmxdcZEjIhP+pWdHXXIw4= on 06/02/2018

Derek M. Klavas, MD Introduction: Our study assessed the effect of total intravenous
Azim Karim, MD anesthesia (TIVA) with short-acting spinal anesthesia and aggressive
day-of-surgery postoperative day 0 physical therapy (POD#0 PT) on
Bradley S. Lambert, PhD
hospital length of stay (LOS) in patients who underwent primary total
Marley Sam Ferris, MD joint arthroplasty.
Domenica Delgado, BS Methods: A retrospective chart review compared the hospital LOS of
Stephen J. Incavo, MD 116 patients who underwent primary total hip arthroplasty and total
knee arthroplasty with TIVA and short-acting spinal blockade
(“Updated protocol group”) with that of the control group of 228
patients who were under standard anesthesia (“Traditional protocol
group”).
Results: Both total hip arthroplasty and total knee arthroplasty
patients in the Updated protocol group had markedly reduced LOS
compared with those in the Traditional protocol group (1.5 6 0.1 days
versus 2.4 6 0.1 days; P , 0.05 and 1.4 6 0.1 days versus 2.3 6
0.1 days; P , 0.05). A higher proportion of patients in the Updated
protocol group received at least 1 POD#0 PT session compared with
those in the Traditional protocol group.
Conclusion: Total intravenous anesthesia combined with short-
acting spinal anesthetics provided the following benefits for patients
who underwent primary total joint arthroplasty: more day-of-surgery
PT sessions and earlier discharge by nearly 1 full day.
Level of Evidence: III.

P rimary total hip arthroplasty

From the Department of Orthopedics,
Houston Methodist Orthopedics &
Sports Medicine, Houston Methodist
Hospital, Houston, TX.
Correspondence to Dr. Incavo:
sjincavo@houstonmethodist.org
J Am Acad Orthop Surg 2018;26:
e221-e229
DOI: 10.5435/JAAOS-D-17-00474
Copyright 2018 by the American
Academy of Orthopaedic Surgeons.
(THA) and primary total knee
arthroplasty (TKA) are two of the
most common orthopaedic proce-
dures currently performed in the
United States, due in part to their
effectiveness and patient satisfaction.
By 2030, the demand for primary
THA and primary TKA is projected
to grow by 174% and 673%,
respectively.1 Because of this antici-
pated growth, reducing hospital
length of stay (LOS) to limit medical
costs remains a focal point for most
high-volume joint arthroplasty cen-
ters. Between 2002 and 2013, the
mean hospital LOS decreased by
approximately 1 day for TKA and
1.25 days for THA, whereas simul-
taneously the mean hospital cost
increased by $7,849 for TKA and
$7,858 for THA.2 This trend has
prompted this past decade’s consid-
erable research efforts placed on
defining rapid-recovery and fast-
track clinical pathways to reduce
hospital LOS. More emphasis is now
being placed on the clinical variables

May 15, 2018, Vol 26, No 10 e221

Copyright ª the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited.
Total Intravenous Anesthesia With Short-acting Spinal Anesthetics in Primary Hip and Knee Arthroplasty

associated with hospital LOS, such as
mode of anesthesia, American Society
of Anesthesiologists (ASA) score,
surgical time, blood loss, postopera-
tive analgesia, postoperative physical
therapy (PT) protocol, and patient
demographics. 3–7 Previously, we
have reported success with day-of-
surgery mobilization postoperative
day 0 (POD#0) at our institution.8
Correlation between the mode of
anesthesia and hospital LOS after
primary total joint arthroplasty (TJA)
is currently a topic of debate.9–12 The
existing standard mode of anesthesia
in joint replacement surgery com-
prises some combination of the
following: general inhaled anes-
thesia and/or neuraxial anesthesia,
regional nerve block, and local
infiltration anesthesia administered
intraoperatively for both TKA and
THA.13 Memtsoudis et al.14 ana-
lyzed the anesthesia records of
.380,000 patients who underwent
primary TJA between 2006 and 2010.
They found that 11% of procedures
were performed under neuraxial
anesthesia only, 14% under combined
neuraxial-general anesthesia, and
75% under general anesthesia only.
In an effort to build on these find-
ings, we recently implemented a
novel anesthesia protocol for pri-
mary THA and TKA that incorpo-
rates total intravenous anesthesia
(TIVA) for general sedation and
short-acting spinal blockade for
neuraxial anesthesia.
The advent of intravenous delivery
for anesthetic agents dates back to the
year 1656 when the aristocrat Robert
Boyle injected opium into the vein
of a dog, noting a “brief period of
anesthesia followed by a full recov-
ery.”15 Large-scale use of intravenous
anesthetics was implemented in the
realm of modern anesthesia in the
early 1990s when short-acting opioids
such as remifentanil were first syn-
thesized. These drugs possess a phar-
macokinetic profile that allows them
to be easily titrated to high levels of
analgesia without causing prolonged
respiratory depression.16 Total intra-
venous anesthesia, a form of general
anesthesia that alleviates the need
for long-acting sedating inhalational
anesthetics, still requires ventilation
with inhaled O2. However, TIVA di-
verges from classic general anesthesia
techniques by using a potent short-
acting opioid such as remifentanil
or fentanyl to provide analgesia, in
combination with another drug, such
as propofol, to provide hypnosis and
amnesia.17 The major benefits of this
drug combination are a completely
attenuated response to noxious in-
traoperative stimuli and rapid post-
operative emergence from sedation.16
Anesthesiologists who cover ambu-
latory surgery cases view TIVA
as a clinically useful modality be-
cause they can safely and predict-
ably awaken their patients from
surgery without having to accom-
modate for prolonged side effects of
anesthesia, such as postoperative
nausea, vomiting, drowsiness, and
fatigue.
Total intravenous anesthesia tech-
niques are generally viewed as safe.
The need for gas delivery systems and
free radical scavenger equipment is
alleviated. Furthermore, TIVA drugs
are less toxic than inhalational drugs
and pose a lower risk of the develop-
ment of malignant hyperthermia.18
When we compared the safety of
TIVA with that of volatile inhaled
anesthetics, we found that previous
studies have yielded no differences.
Total intravenous anesthesia main-
tained comparable hemodynamic
parameters with fewer episodes of
bradycardia in patients who under-
went coronary artery bypass graft
procedures.19 In addition, postcardiac
surgery measurements of the liver and
renal function were found to be sim-
ilar in patients who received either
TIVA or inhaled anesthetics.20
The goal of implementing an up-
dated protocol is to achieve safe, rapid
recovery while maintaining excellent
pain control. Improving postoperative
pain control facilitates earlier mobili-
zation and accelerated PT, two factors
that have proved to reduce the mean
LOS after primary TJA.21,22 The pur-
pose of this study was to (1) investi-
gate how hospital LOS after primary
TJA was affected when patients re-
ceived a novel mode of anesthesia
consisting of TIVA combined with a
short-acting spinal anesthetic and (2)
determine whether the updated anes-
thesia protocol facilitated quicker
postoperative mobilization while
maintaining patient safety both
during their hospital stay and after
discharge. We hypothesized that
this updated protocol would result
in improved postoperative mobili-
zation with a clinically significant
reduction in hospital LOS and no
significant increase in 30-day com-
plication rates.
Methods
Study Design
After institutional review board
approval was obtained, we retro-
spectively reviewed the use of the
updated anesthesia protocol identi-
fied as the “Updated protocol group”
for primary THA and TKA patients
compared with the control group,

Dr. Incavo has received royalties from Innomed, Kyocera, OsteoRemedies, Smith & Nephew, Wright Medical Technology, and Zimmer;
serves as a paid consultant to Zimmer; holds stock or stock options in Nimbic Systems and Medical/Orthopaedic publications editorial/
governing board (Journal of Arthroplasty); and is a board member or committee member of the Knee Society. None of the following authors
or any immediate family member has received anything of value from or has stock or stock options held in a commercial company or
institution related directly or indirectly to the subject of this article: Dr. Klavas, Dr. Karim, Dr. Lambert, Dr. Ferris, and Ms. Delgado.

e222 Journal of the American Academy of Orthopaedic Surgeons

Copyright ª the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited.

consisting of primary THA and TKA
patients with a standard anesthesia
protocol identified as the “Tradi-
tional protocol group.” The senior
orthopaedic surgeon performed the
procedures on these patients between
January 2014 and December 2014.
Data collected for the Updated pro-
tocol group were obtained through a
review of the charts of all primary
THA and TKA surgeries performed
by the same surgeon over the course
of a 6-month period from June 2016
to December 2016 immediately after
the initiation of the updated anes-
thesia protocol. All surgeries took
place at a single tertiary care center
with operating rooms (ORs) and
ancillary staff dedicated to ortho-
paedic surgical procedures. The
inclusion criterion was any adult
patient who underwent primary
elective unilateral TJA of the hip or
knee during the study period. The
exclusion criterion was any patient
who underwent revision joint ar-
throplasty, bilateral joint arthro-
plasty during the same hospital stay,
unicompartmental joint arthro-
plasty, or THA performed for fem-
oral neck fractures. After inclusion
and exclusion criteria were applied, a
total of 235 consecutive patients
(116 THA and 119 TKA), who
underwent primary elective joint
arthroplasty during the Traditional
protocol study period, and a total of
118 consecutive patients (59 THA
and 59 TKA), who underwent pri-
mary elective joint arthroplasty
during the updated protocol study
period, were included. All patients
who met the study criteria were
included for analysis, despite age or
comorbidities.
Medical hospital charts were re-
viewed for patient demographics, in-
traoperative data, postoperative
course, progress notes, nursing notes,
and physical therapist notes. Patient
records were also reviewed for com-
plications and readmissions for a
period up to 30 days after discharge.
May 15, 2018, Vol 26, No 10
Copyright ª the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited.
Follow-up in the office for wound
assessment, radiographs, and range
of motion assessment was docu-
mented with a progress note at 2 to 3
weeks postoperatively. All patients
who met the inclusion criteria were
followed up.
Hospital LOS was measured from
the time of admission in the pre-
operative holding area on the day of
surgery to the time of discharge from
the hospital, as documented by
the charge nurse in the acute care
orthopaedic unit. Physical therapy
sessions for patient ambulation were
conducted on the day of surgery
(POD#0) and each subsequent day
until discharge. These sessions re-
mained consistent across both study
groups in THA and TKA patients
alike, with up to three daily sessions
directed at early mobilization, range
of motion exercises, and strength-
building exercises. Physical therapy
was performed after patient consent
was obtained.
Anesthesia Protocols
For the Traditional protocol group, a
combination of general anesthesia
and long-acting neuraxial anesthesia
was used for both THA and TKA
patients. General anesthesia con-
sisted of inspired sevoflurane gas
with O2 via endotracheal tube air-
way. Neuraxial anesthesia consisted
of 0.2 mg of morphine administered
via one-time spinal injection into the
thecal sac. Peripheral nerve blocks
for TKA patients were not per-
formed. Foley catheters were placed
preoperatively after intubation for all
patients in the Traditional protocol
group to avoid urinary retention with
long-acting spinal blockade. All Foley
catheters were removed on POD#1,
unless medically indicated for pro-
longed use.
For the Updated protocol group, a
combination of TIVA and short-
acting spinal anesthesia was used.
Total intravenous anesthesia con-
Derek M. Klavas, MD, et al
sisted of a propofol intravenous
bolus using weight-based dosing,
followed by continuous intravenous
propofol infusion, with a combina-
tion of fentanyl, remifentanil, or hy-
dromorphone for narcotic analgesia.
In all cases, the amounts of these
drugs were titrated at the discretion
of the anesthesiologist to maintain an
adequate depth of anesthesia. Venti-
lation was maintained with inhaled
O2 via either laryngeal mask airway
or endotracheal intubation. Neu-
raxial anesthesia consisted of 0.75%
bupivacaine administered via one-
time injection into the thecal sac by
the attending anesthesiologist. Foley
catheters were not used in the Up-
dated protocol group, unless indi-
cated for a medical reason. Unless
contraindicated, all TKA recipients
also received an ultrasonography-
guided saphenous nerve block with
0.2% ropivacaine, 100 mg of cloni-
dine, and 5 mg of dexamethasone
at the adductor canal (Table 1).
There were no contraindications for
saphenous nerve blockade. How-
ever, the success of every nerve
blockade was judged preoperatively
by both delivering anesthesiologist
and senior orthopaedic surgeon.
Surgery
In addition to the respective anesthe-
sia protocols just described, 10 mg/kg
of intravenous tranexamic acid
was administered in all cases to help
limit blood loss, and 10 mg of intra-
venous dexamethasone was admin-
istered intraoperatively to minimize
postoperative nausea. All THA
procedures in the study were per-
formed with conventional instru-
ments and uncemented components
through a minimally invasive poste-
rior approach, direct anterior ap-
proach, or anterolateral approach.
All TKA procedures were performed
with a standard medial parapatellar
approach, conventional instruments,
and a tourniquet. The patella was
e223
Total Intravenous Anesthesia With Short-acting Spinal Anesthetics in Primary Hip and Knee Arthroplasty

Table 1
Description of Perioperative Anesthesia Protocols
Perioperative Variable Traditional Anesthesia Protocol Updated Anesthesia Protocol

Generala Inhaled sevoflurane 1 O2 Propofol 6 fentanyl/remifentanil/

hydromorphone 1 O2
Neuraxial Intrathecal morphine 0.2 mg 6 Intrathecal 0.75% bupivacaine 6
fentanyl 20 mg fentanyl 20 mg
Regional (TKA only) None 0.2% Ropivacaine, clonidine 100 mg,
and dexamethasone 5 mg through
the adductor canal
Local infiltration (intraoperatively)
THA 0.25% Ropivacaine, 0.5% 0.25% Ropivacaine, 0.5%
ropivacaine, and 1:1000 ropivacaine, and 1:1000
epinephrine epinephrine
TKA Exparel, 0.25% bupivacaine with Exparel, 0.25% bupivacaine with
epinephrine, 10 mg morphine, and epinephrine, 10 mg morphine, and
30 mg ketorolac 30 mg ketorolac
Prophylaxisb Dexamethasone 5–10 mg and Dexamethasone 5–10 mg and
tranexamic acid 10 mg/kg tranexamic acid 10 mg/kg
(maximum 1 g) (maximum 1 g)
Foley catheter? Yes No

THA = total hip arthroplasty, TKA = total knee arthroplasty

a
Actual doses titrated to maintain an adequate depth of anesthesia.
b
Varies based on the number and complexity of medical comorbidities.

resurfaced, and cement fixation was
used in all patients. Drains were not
used for any THA or TKA cases.
Before closure in all cases, a locally
injected anesthetic cocktail was used
to assist with postoperative analgesia
(Table 1).
Postoperative Care
Postoperative day 0 PT was con-
ducted for all patients in the study.
For the Traditional protocol group,
one PT/ambulatory session was
offered on the day of surgery. For
the Updated protocol group, day-
of-surgery ambulation was offered
for three sessions to emphasize
rapid mobilization. Patients did not
undergo formal PT before surgery.
The PT protocol for both groups
consisted of subjective assessment
of patient condition, lower limb–
strengthening exercises, and maxi-
mum gait training with the use
of an assistive walking device as
needed. Posterior hip movement
precautions were taken for any
patient who underwent posterolat-
eral approach THA to protect
against postoperative dislocation.
Continuous passive motion was not
used in any TKA patient in this
study.
Patients were cleared for discharge
by a multidisciplinary team after they
met the following criteria: absence of
comorbid medical conditions neces-
sitating inpatient management, intact
surgical incisions with no evidence of
surrounding erythema without dis-
charge, intact lower extremity neu-
rovascular examination, adequate
pain control with oral analgesics,
and all PT goals achieved (indepen-
dence with bed mobility, indepen-
dent transfers, standing balance,
and a minimum gait distance of
150 ft). Patients who were unable
to be discharged home were trans-
ferred to skilled nursing facilities
or home health care. Follow-up
appointments were arranged for 2
to 3 weeks postoperatively.
Excluded Patients
Of the 235 patients who met the
inclusion criteria and underwent pri-
mary elective joint arthroplasty by
traditional anesthesia methods, 7
patients (4 THA and 3 TKA) were
excluded from analysis in the Tradi-
tional protocol group because of
complications that prolonged hospi-
tal LOS. Of the 118 patients who met
the inclusion criteria and underwent
primary elective joint arthroplasty
by updated anesthesia methods, 2
patients (1 THA and 1 TKA) were
excluded from analysis in the Up-
dated protocol group because of
complications that prolonged hospi-
tal LOS (Table 2).
Statistical Analysis
Within each protocol group, data were
analyzed using both combined and
separate observations from THA and
TKA procedures. Age, body mass
index (BMI), LOS, surgery time, time
spent in the postanesthesia care unit

e224 Journal of the American Academy of Orthopaedic Surgeons

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 Derek M. Klavas, MD, et al

Table 2
Description of Excluded Patients
Age (y)/Sex Surgery LOS (d) Complication

Traditional group (seven excluded patients)

61/male TKA 3 DVT
61/male THA 16 Postoperative NSTEMI and respiratory
insufficiency
73/male THA 14 Evacuation of hematoma in the OR due to
neurovascular compromise
74/male TKA 4 Immunocompromised transplant patient, C. Diff1
74/female THA 5 Dysphagia
68/female TKA 4 Asthma exacerbation
84/female THA 9 Ogilvie syndrome, C. Diff1
Updated group (two excluded patients)
84/male TKA 9 Delirium and agitation
36/female THA 4 Immunocompromised transplant patient

C. Diff = Clostridium difficile, DVT = deep vein thrombosis, LOS = length of stay, NSTEMI = non–ST-elevated myocardial infarction, OR = operating
room, THA = total hip arthroplasty, TKA = total knee arthroplasty

(PACU), estimated blood loss (EBL),
and the number of PT sessions con-
ducted were compared between groups
(Traditional versus Updated protocol)
using an independent two-tailed t-test.
Chi-square analysis was used to
compare the percentage of patients
within each group who received PT on
the day of surgery and the ASA
Physical Status Classification (1 to 4).
Type I error was set at a = 0.05 for all
analyses. For all statistically significant
differences (P , 0.05), the effect size
was calculated using either a Cohen
D statistic (t-test analysis) or a phi
statistic (chi-square analysis). To
quantify the size of any observed dif-
ferences between the two protocol
groups, Cohen D and phi statistic
were interpreted as follows: ,0.1,
negligible effect size; 0.1 to 0.3, small
effect size; 0.3 to 0.5, moderate effect
size; 0.5 to 0.7, large effect size; and
.0.7, very large effect size. All data
were analyzed using SPSS software for
Windows (version 20; IBM Statistics).
Results
For all primary TJA recipients
included in the analysis of this
study, there were no significant dif-
ferences between the two groups
with regard to age, BMI, and ASA
status. However, surgery time (79.8
6 1.4 minutes versus 69.4 6
1.4 minutes; P , 0.01), EBL (175.4
6 10.5 mL versus 112.4 6 10.4 mL;
P , 0.01), and length of time in the
PACU (133.5 6 4.8 minutes versus
115.8 6 4.2 minutes; P , 0.05) were
each significantly higher for the
Traditional protocol group than
those for the Updated protocol group
(Supplemental Table 3, Supplemental
Digital Content 1, http://links.lww.
com/JAAOS/A90). The Cohen D
statistic was 0.58 (large effect) for
surgery time, 0.46 (moderate effect)
for EBL, and 0.30 for time spent in
the PACU (moderate effect). A similar
proportion of patients attended at
least four or more PT sessions before
discharge in both groups: 116/228
(50.8%) in the Traditional group and
60/116 (51.7%) in the Updated
group. For the total number of PT
sessions attended before discharge,
only the subset of THA patients
showed any difference (P , 0.05):
mean 3.6 6 0.1 sessions before dis-
charge in the Traditional protocol
group versus 4.3 6 0.2 sessions
before discharge in the Updated
protocol group. The effect size for
this difference was 0.44 (moderate).
Overall, there were a significantly
greater proportion of patients in
the Updated protocol group who
received POD#0 PT (87.1%) com-
pared with the Traditional protocol
group (66.7%) (P , 0.05). This dif-
ference had an effect size of 0.22
(small) (Supplemental Table 3, Sup-
plemental Digital Content 1, http://
links.lww.com/JAAOS/A90).
With regard to the hospital LOS of
all patients who underwent either
THA or TKA in this study, the Up-
dated protocol group had a mean
LOS of 1.4 6 0.1 days. This was
markedly lower than in the Tradi-
tional protocol group, which had a
mean LOS of 2.3 6 0.1 days (P ,
0.01). The subset of THA patients in
the Updated protocol group had a
mean hospital LOS of 1.5 6 0.1 days
compared with 2.4 6 0.1 days for
THA patients in the Traditional
protocol group (P , 0.01). Total
knee arthroplasty patients in the
Updated protocol group had a mean
hospital LOS of 1.4 6 0.1 days

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Copyright ª the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited.
Total Intravenous Anesthesia With Short-acting Spinal Anesthetics in Primary Hip and Knee Arthroplasty
Figure 1
Graph showing the percentage of patients remaining in the hospital over the first
6 days after total joint arthroplasty comparing a traditional anesthesia protocol
with an updated anesthesia protocol.
compared with 2.3 6 0.1 days for
TKA patients in the Traditional
protocol group (P , 0.01) (Supple-
mental Table 3, Supplemental Digi-
tal Content 1, http://links.lww.com/
JAAOS/A90). The effect size as
measured by the Cohen D statistic
was considered very large when
comparing the differences in the LOS
of all primary joint recipients (0.90),
THA alone (0.86), and TKA alone
(0.98).
The percentage of patients remain-
ing in the hospital after POD#1 was
91.2% for the Traditional protocol
group and 31.9% for the Updated
protocol group. By POD#2, 32.2%
of patients in the Traditional pro-
tocol group remained hospitalized
compared with 8.6% of patients in
the Updated protocol group. By
POD#4, 2.6% of patients in the
Traditional protocol group remained
hospitalized, whereas all patients
from the Updated protocol group
were discharged (Figure 1).
There were no hospital read-
missions for postoperative compli-
cations within 30 days in the
Traditional protocol group. The
e226
Copyright ª the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited.
Updated protocol group had 1 TKA
patient who, 2 weeks after discharge,
presented with a fall at home with
wound dehiscence and was treated
with irrigation and débridement in
the OR and 6 weeks of intravenous
antibiotics. The Traditional protocol
group had two patients who sus-
tained a mechanical fall in the hos-
pital before discharge, whereas the
Updated protocol group had no
patients who sustained a mechanical
fall before discharge. Of note, 92.5%
of patients in the Traditional pro-
tocol group were discharged to home
compared with 95.8% of patients in
the Updated protocol group. The
remaining patients were discharged
to a supervised setting.
Discussion
Factors that enable expeditious dis-
charge from the hospital after pri-
mary elective total joint surgery
include adequate postoperative
analgesia, short-lived side effects of
anesthetics, patient motivation, and
clinical pathways that promote early
Journal of the American Academy of Orthopaedic Surgeons
and aggressive rehabilitation by
physical therapists.23,24 However,
because hospital LOS has gradually
shortened in recent years, the con-
cern surrounding patient safety and
increased risk of complications has
heightened. A major risk associated
with aggressive PT is hip dislocation
after THA. Fortunately, no hip dis-
locations were reported in our
cohort of patients. Other minor
postoperative risks include pro-
longed swelling, bleeding from the
surgical site, urinary tract infections,
and surgical site infections. Major
postoperative risks are pulmonary
embolism, myocardial infarction,
and deep surgical wound infection
necessitating return to the OR.
Minor complications that occur
after discharge are not always re-
ported by the patient; therefore, their
true incidence in our study pop-
ulation after discharge is unknown.
Nevertheless, we are able to report
that there were two major complica-
tions necessitating return to the OR
and/or a hospital readmission within
30 days: 1 patient in the Traditional
protocol group who was taken back
to the OR on the same day of surgery
for evacuation of a hematoma (Table
2) and 1 patient readmitted to the
hospital for wound dehiscence after
a fall, necessitating irrigation and
débridement and intravenous anti-
biotics. This equates to a major
complication rate of 0.56% and a
readmission rate of 0.29%. Data
from the American College of Sur-
geon’s National Surgical Quality
Improvement Program on elective
primary TJA patients show that the
30-day readmission rate after elec-
tive primary TJA is 4.6% for TKA
and 4.2% for THA,25 which is much
higher than the rate reported in the
current study. One possible reason
for this discord is that the current
study only screened for readmission
to the same institution and may have
missed patients who were readmitted
elsewhere. Similarly, data from the

American College of Surgeon’s
National Surgical Quality Improve-
ment Program show that hospital
discharge within 2 days from surgery
does not increase the risk of major
complications and hospital read-
mission. Patient demographics (BMI,
ASA score, and medical comorbid-
ities) and perioperative variables
(surgery time and blood loss) were
attributed to an increased risk of
major complications.26
Three perioperative variables mea-
sured in this study (surgery time,
estimated blood loss [EBL], and
length of time spent in the PACU)
were found to be significantly lower
in the Updated protocol group com-
pared with the Traditional protocol
group. The authors think that shorter
surgery times may be due to bias in
favor of the Updated protocol group,
whose patients underwent surgery
over a period of time 2 years later
than the Traditional protocol group.
Such an advantage in chronicity
could potentially grant the Updated
protocol group with the benefit of
more intraoperative experience and
familiarity. The observed difference
in EBL can be explained by institu-
tional changes in the way blood loss is
reported in the electronic medical
record after surgery. For the Tradi-
tional protocol, the anesthesiologist
alone estimates blood loss, whereas
for the Updated protocol, the anes-
thesiologist and attending surgeon
estimate blood loss after discussing
with one another. Nevertheless,
increased surgical time and increased
blood loss have been previously
described to positively correlate with
prolonged hospital LOS.7 Our anal-
ysis did not control for perioperative
variables when analyzing hospital
LOS between the two study groups.
The results of our study show
that TIVA used in conjunction
with short-acting nonopioid spinal
anesthetics facilitated earlier post-
operative mobilization in a safe
manner and led to markedly reduced
May 15, 2018, Vol 26, No 10
Copyright ª the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited.
LOS in the hospital, validating the
study hypothesis. The incidence of
complications and hospital read-
mission in the cohort of patients in
the current study who received TIVA
was much lower than what is re-
ported in the literature,25 attesting to
the safety of this perioperative pro-
tocol. Furthermore, because the
Updated protocol replaced a long-
acting spinal anesthetic with a short-
acting spinal anesthetic, we were
able to discontinue the routine use of
Foley catheters.
Correlation between aggressive
postoperative rehabilitation (including
day-of-surgery ambulation) and de-
creased hospital LOS is an evolving
concept in the subspecialty of joint
replacement surgery.4–7,21–23,27,28 This
retrospective review was conducted on
patients who underwent uncompli-
cated primary joint replacement after a
modified early ambulation program
was implemented on the acute care
orthopaedic unit at our institution. As
part of this enhanced recovery pro-
gram, PT protocols were altered such
that three daily walking sessions were
offered. Both groups in the current
study had the benefit of this aggressive
mobilization regimen to their advan-
tage, confirmed by an insignificant
difference in the total number of PT
sessions received before discharge (3.7
6 0.1 versus 4.0 6 0.2; P . 0.05)
(Supplemental Table 3, Supplemental
Digital Content 1, http://links.lww.
com/JAAOS/A90). On a similar note,
neither group trended toward a higher
likelihood of being discharged to a
skilled nursing facility or long-term
acute care facility, further supporting
the advantages provided by rapid
mobilization.
Based on the results of this study,
the authors propose that TIVA with a
short-acting nonopioid spinal anes-
thetic and no routine Foley catheter
use markedly increases a patient’s
likelihood of ambulating on the
day of surgery in an enhanced
recovery program. The current study
Derek M. Klavas, MD, et al
advances the discussion surrounding
the efficacy of TIVA and short-acting
spinal anesthesia on clinical out-
comes in primary joint arthroplasty,
which has limited reports in the lit-
erature. Two randomized controlled
trials conducted by Harsten et al11,12
at a Swedish fast-track joint arthro-
plasty center looked at recovery
times after TJA in patients receiving
solely TIVA versus solely spinal
blockade. In patients who received
only TIVA, they reported a median
time to meet discharge criteria of 26
hours in their THA cohort and a
median time to meet discharge cri-
teria of 46 hours in their TKA
cohort. The current study reports a
mean hospital LOS of 40.9 hours in
THA patients and 38.2 hours in
TKA patients. Our methods differ
in that we did not specify “meeting
discharge criteria” as the end point
when we measured hospital stay.
Instead, we used the time of physical
discharge from the hospital, thus
potentially increasing the mean LOS
compared with other studies.
Our finding of a reduced hospital
LOS by approximately 22 hours (0.9
day) holds clinical significance in
addition to statistical significance.
Although it would have been inap-
propriate and may have introduced
study bias to preemptively declare a
cutoff for reduction in LOS as clini-
cally significant, the authors retro-
spectively propose that any reduction
in LOS .12 hours should be in-
terpreted as clinically beneficial.
For example, a difference in this
magnitude could reflect one of two
scenarios: (1) an early morning dis-
charge on POD#2 as opposed to
evening or (2) an evening discharge
on POD#2 as opposed to an addi-
tional night in the hospital before
discharging the morning of POD#3.
In either instance, the reduction in
LOS portends to reduced utilization
of hospital resources, decreased
overall costs, and increased patient
satisfaction.
e227
Total Intravenous Anesthesia With Short-acting Spinal Anesthetics in Primary Hip and Knee Arthroplasty
The study is limited by its retrospec-
tive nature, relatively small sample size,
and asymmetry between study group
sizes. A retrospective study design
made it difficult to collect data on
postoperative nausea, vomiting, and
visual analog scale pain scores because
these values were inconsistently re-
corded in the patients’ medical chart;
however, it is our observation that
postoperative nausea and vomiting
were greatly reduced in patients who
did not receive inhaled anesthetics.
The statistical analysis did not control
for certain perioperative factors that
may have influenced study results.
Furthermore, the analysis did not
take into account how the surgical
approach affected LOS, how the day
of surgery affected LOS, or how the
time of surgery start may affect LOS.
Moving forward, now that our in-
stitution has transitioned to the Up-
dated protocol for 100% of elective
primary TJA procedures, reimple-
menting a Traditional protocol to
perform a randomized controlled
trial comparing the two groups
would not be in the best interest of
our patients. The data presented
show clear improvement in the
postoperative course with direct
patient benefits at no additional risk
to patient safety. The strengths of
this study include its adequate sta-
tistical power, measure of effect size,
lack of difference in age, sex, BMI,
or ASA status, and reproducible
methods for potential use in future
investigations.
Conclusion
These results provide useful infor-
mation for any individual surgeon or
group of surgeons who regularly
perform primary elective TJA and
wish to decrease their patients’ post-
operative LOS. With decreased
LOS comes improved cost of care.
Because greater importance is placed
on value-based care within bundled-
e228
Copyright ª the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited.
care settings, improvements such as
these will be necessary. Our results
indicate that TIVA and short-acting
nonopioid spinal anesthetics are a
promising route toward achieving
decreased hospital LOS after TJA.
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