Abstract
Surgical repair of hip fracture and total hip arthroplasty are primarily performed on elderly patients. Patients presenting for hip fracture surgery have a high prevalence of preoperative medical problems and may require medical stabilization before surgery. Regional anaesthesia for hip fracture repair may be contraindicated due to perioperative pharmacologic prophylaxis for deep venous thrombosis. The use of regional anaesthesia increases the magnitude and frequency of hypotensive episodes when compared with general anaesthesia. Intraoperative blood losses, averaging 250–300 ml, are not affected by anaesthetic technique. Following hip fracture surgery under spinal anaesthesia, patients exhibit better oxygenation in the early postoperative period than those after general anaesthesia. The frequency of postoperative confusion is unrelated to anaesthetic technique. The incidence of deep venous thrombosis is reduced following spinal anaesthesia as compared with general anaesthesia. The one-month mortality rate, approximately eight per cent, is unrelated to anaesthetic technique. Spinal, epidural and general anaesthesia have been used successfully for total hip arthroplasty. Intraoperative blood loss of 0.5− 1.5 litres is reduced with regional anaesthesia. General anaesthesia with controlled hypotension also significantly reduces blood loss. Intraoperative instability with hypoxaemia, hypotension and cardiac arrest may follow impaction of the femoral prosthesis and are related to absorption of acrylic cement monomers and pulmonary embolism of fat, air, and plateletfibrin aggregates. Postoperative deep venous thrombosis is common and the incidence may be reduced with epidural anaesthesia. Operative mortality is less than one per cent and pulmonary embolism is the commonest cause of death. Data relating mortality to anaesthetic technique do not exist. Anaesthetic technique for hip fracture surgery does not appear to significantly alter morbidity or mortality. Regional anaesthesia for total hip arthroplasty reduces deep venous thrombosis, pulmonary embolism, and blood loss and may be the preferred technique, alone or in combination with general anaesthesia. et même un arrêt cardiaque dont les mécanismes vont de l’absorption de monomères d’acrylique à l’embolisation des artères pulmonaires par de l’air, des particules graisseuses ou des agrigats plaquettaires. On sait par ailleurs que l’anesthisie peridurale reduit le risque de thrombose veineuse profonde, complication frequente, et que l’embolie pulmonaire est responsable de la majorité des déces survenant en période péri=opératoire (moins de un pour cent des cas). Cependant aucune relation entre le type d’anesthésie et la mortalité n’a été établie. La morbidité et la mortalité associées au traitement chirurgical des fractures de la hanche ne semblent pas influenciés de façon significative par le type d’anesthésie. Pour les arthroplasties totales de la hanche, l’anesthisie régionale comporte moins de risques de thrombose veineuse et d’embolie pulmonaire, elle minimise les pertes sanguines et s’avère peut- être la technique de choix, seule ou combinée à l’anesthésie générale.
Article PDF
Similar content being viewed by others
References
Sisk TD. Fractures of the hip and pelvis.In: Campbell’s Operative Orthopaedics, vol 3. Crenshaw AH (Ed.). St. Louis: The C.V. Mosby Company, 1987: 1719–81.
Total hip-joint replacement in the United States. Consensus development conference of the National Institute of Health. JAMA 1982; 248: 1817–21.
United States Congress Office of Technology Assessment. The context of the report.In: Life sustaining technologies and the elderly. Washington, DC: United States Government Printing Office, 1987: 39–88.
Kelsey JL, Hoffman S. Risk factors for hip fracture. N Engl J Med 1987; 316: 404–6.
Gallannaugh SC, Martin A, Millard PH. Regional survey of femoral neck fractures. Br Med J 1976; 2: 1496–7.
Editorial. The old woman with a broken hip. Lancet 1982; 2:419-20.
Jensen JS, Tondevold E. Mortality after hip fractures. Acta Orthop Scand 1979; 50: 161–7.
Cummings SR, Kelsey JL, Nevitt MC, O’Dowd KJ. Epidemiology of osteoporosis and osteoporotic fractures. Epidemiol Rev 1985; 7: 178–208.
Melton LJ III,Wahner HW, Richelson LS, O’Fallon WM, Riggs BL. Osteoporosis and the risk of hip fracture. Am J Epidemiol 1986; 124: 254–61.
Davis FM, Woolner DF, Frampton C et al. Prospective, multi-centre trial of mortality following general or spinal anaesthesia for hip fracture surgery in the elderly. Br J Anaesth 1987; 59: 1080–8.
Berggren D, Gustafson Y, Eriksson B et al. Postoperative confusion after anaesthesia in elderly patients with femoral neck fractures. Anesth Analg 1987; 66: 497–504.
Abdon NJ, Nilsson BE. Episodic cardiac arrythmia and femoral neck fracture. Acta Med Scand 1980; 208: 73–6.
Ceder L, Elmgvist D, Svensson S. Cardiovascular and neurological function in elderly patients sustaining a fracture of the neck of the femur. J Bone Joint Surg 1981; 63B:560–6.
Rashiq S, Logan RF. Role of drugs in fractures of the femoral neck. Br Med J 1986; 292: 861–3.
Ray WA, Griffin MR, Schaffner W, Baugh DK, Melton JL III. Psychotropic drug use and the risk of hip fracture. N Engl J Med 1987; 316: 363–9.
Martin VC. Hypoxaemia in elderly patients suffering from fractured neck of femur. Anaesthesia 1977; 32: 852–67.
McKenzie PJ, Wishart HY, Dewar KMS, Gray I, Smith G. Comparison of the effects of spinal anaesthesia and general anaesthesia on postoperative oxygenation and perioperative mortality. Br J Anaesth 1980; 52: 49–53.
Davidson TI, Bodey WN. Factors influencing survival following fractures of the upper end of the femur. Injury 1986; 17: 12–4.
Kenzora JE, McCarthy RE, Lowell JD, Sledge MD. Hip fracture mortality. Clin Orthop 1987; 223: 188–93.
Soreide O, Molster A, Raugstad TS. Internal fixation versus primary prosthetic replacement in acute femoral neck fractures: a prospective, randomized clinical study. Br J Surg 1979; 66: 56–60.
DeLee JC. Fractures and dislocations of the hip.In: Fractures in Adults, vol 2. Rockwood CA Jr, Green DP (Eds.). Philadelphia: J. B. Lippincott Company, 1984; 1211–1356.
Winter WG. Nonoperative treatment of proximal femoral fractures in the demented, nonambulatory patient. Clin Orthop 1987; 218: 97–103.
Lyon LJ, Nevins MA. Management of hip fractures in nursing home patients: to treat or not to treat? J Am GeriatrSoc 1984; 32: 391–5.
Gotfried Y, Frish E, Mendes DG, Roffman M. Intertrochanteric fractures in high risk geriatric patients treated by external fixation. Orthopedics 1985; 8: 769–74.
McKenzie PJ, Loach AB. Local anaesthesia for orthopaedic surgery. Br J Anaesth 1986; 58: 779–89.
Wickstrom I, Holmberg I, Stefansson T. Survival of female geriatric patients after hip fracture surgery. A comparision of 5 anesthetic methods. Acta Anaesthesiol Scand 1982; 26: 607–14.
Paiement GD, Essinger SJ, Harris WH. Survey of prophylaxis against venous thromboembolism in adults undergoing hip surgery. Clin Orthop 1987; 223: 188–93.
Murphy TM. Spinal, epidural, and caudal anaesthesia.In: Anesthesia, vol 2. Miller RD (Ed.). New York: Churchill Livingstone, 1986; 1061–1111.
Owens EL, Kasten GW, Hessel EA II. Spinal subarachnoid hematoma after lumbar puncture and heparinization. Anesth Analg 1986; 65: 1201–7.
Haljamae H, Stefansson T, Wickstrom I. Preanesthetic evaluation of the female geriatric patient with hip fracture. Acta Anaesthesiol Scand 1982; 26: 393–402.
Valentin N, Lomholt B, Jensen JS, Hejgaard N, Kreiner S. Spinal or general anaesthesia for surgery of the fractured hip? BrJ Anaesth 1986; 58: 284–91.
Davis FM, Laurenson VG. Spinal anaesthesia or general anaesthesia for emergency hip surgery in elderly patients. Anaesth Intensive Care 1981; 9: 352–8.
McKenzie PJ, Wishart HY, Gray I, Smith G. Effects of anaesthetic technique on deep vein thrombosis. Br J Anaesth 1985; 57: 853–7.
McKenzie PJ, Wishart HY, Smith G. Long term outcome after repair of fractured neck of femur. Br J Anaesth 1984; 56: 581–4.
Williams MA, Holloway JR, Winn MC et al. Nursing activities and acute confusional states in elderly hipfractured patients. Nurs Res 1979; 28: 25–35.
Tune LE, Holland A, Folstein MF et al. Association of postoperative delirium with raised serum levels of anticholinergic drugs. Lancet 1981; 2: 651–3.
Davison LA, Steinhelber JC, Eger El II,Stevens WC. Psychological effects of halothane and isoflurane anaesthesia. Anesthesiology 1975; 43: 313–24.
Bigler D, Adelhoj B, Petring OU, Pederson NO, Busch P, Kalhke P. Mental function and morbidity after acute hip surgery during spinal and general anaesthesia. Anaesthesia 1985; 40: 672–6.
Salzman EW, Harris WH. Prevention of venous thromboembolism in orthopaedic patients. J Bone Joint Surg 1976; 58A: 903–13.
Sharnoff JG, Rosen RL, Sadler AH, Ibarra-Isunza GC. Prevention of fatal pulmonary thromboembolism by heparin prophylaxis after surgery for hip fractures. J Bone Joint Surg 1976; 58A: 913–8.
Davis FM, Quince M, Laurenson VG. Deep vein thrombosis and anaesthetic technique in emergency hip surgery. Br Med J 1980; 281: 1528–9.
Miller CW. Survival and ambulation following hip fracture. J Bone Joint Surg 1978; 60A: 930–4.
McLaren AD, Stockwell MC, Reid VT. Anaesthetic techniques for surgical correction of fractured neck of femur. Anaesthesia 1978; 33: 10–4.
White IW, Chappell WA. Anaesthesia for surgical correction of fractured femoral neck. Anaesthesia 1980; 35: 1107–10.
Liang MH, Cullen KE, Larson MG et al. Cost-effectiveness of total joint arthroplasty in osteoarthritis. Arthritis Rheum 1986; 29: 937–43.
Liang MH, Cullen KE, Pass R. Primary total hip or knee replacement: evaluation of patients. Ann Intern Med 1982; 97: 735–9.
Calandruccio RA. Arthroplasty of hip.In: Campbell’s Operative Orthopedics, vol 2. Crenshaw AH (Ed.). St. Louis: The C.V. Mosby Company, 1987; 1213–1501.
Melton JL III,Stauffer RN, Chao EY, Ilstrup DM. Rates of total hip arthroplasty. N Engl J Med 1982; 307: 1242–5.
Gibb PS, Kim KC. Skin and musculoskeletal diseases.In: Anaesthesia and Co-existing Disease. Stoelting RK, Dierdorf SF (Eds.)- New York: Churchill Livingstone, 1983; 573–603.
Koide M, Pilone RN, Vandam LD, Lowell JD. Anaesthetic experience with total hip replacement. Clin Orthop 1974; 99: 78–85.
Chin SP, Abou-Madi MN, Eurin B, Witvoet J, Montagne J. Blood loss in total hip replacement: extradural v. phenoperidine analgesia. Br J Anaesth 1982; 54: 491–4.
Modig J, Busch C, Olerud S, Saldeen T. Pulmonary microembolism during intramedullary orthopedic trauma. Acta Anaesthesiol Scand 1974; 18: 133–43.
Modig J, Borg T, Karlstrom G, Maripuu E, Sahlstedt B. Thromboembolism after total hip replacement: role of epidural and general anesthesia. Anesth Analg 1983; 62: 174–80.
Fredin H, Gustafson C, Rosberg B. Hypotensive anesthesia, thromboprophylaxis and postoperative thromboembolism in total hip arthroplasty. Acta Anaesthesiol Scand 1984; 28: 503–7.
Total hip-joint replacement in Sweden. Consensus development conference of the National Institute of Health. JAMA 1982; 248: 1822–4.
Sculco TP, Ranawat C. The use of spinal anesthesia for total hip-replacement arthroplasty. J Bone Joint Surg 1975; 57-A: 173–7.
Davis FM, Laurenson VG, Lewis J, Wells JE, Gillespie WJ. Metabolic response to total hip arthoplasty under hypobaric subarachnoid or general anesthesia. Br J Anaesth 1987; 59: 725–9.
Modig J, Maripuu E, Sahlstedt B. Thromboembolism following total hip replacement. Reg Anaesth 1986; 11: 72–9.
Rosberg B, Fredin H, Gustafson C. Anesthetic techniques and surgical blood loss in total hip arthroplasty. Acta Anaesthesiol Scand 1982; 26: 189–93.
Keith I. Anesthesia and blood loss in total hip replacement. Anaesthesia 1977; 32: 444–50.
Barbier-Bohm G, Desmonts JM, Coudero E, Moulin D, Prokocimer P, Oliver H. Comparative effects of induced hypotension and normovolemic haemodilution on blood loss in total hip arthroplasty. Br J Anaesth 1980; 52: 1039–43.
Thorburn J, Louden JR, Vallance R. Spinal and general anaesthesia in total hip replacement: frequency of deep vein thrombosis. Br J Anaesth 1980; 52: 1117–20.
Thorburn J. Subarachnoid blockade and total hip replacement. Br J Anaesth 1985; 57: 290–3.
Amaranath L, Cascorbi HF, Singh-Amaranath AV, Frankmann DB. Relation of anaesthesia to total hip replacement and control of operative blood loss. Anesth Analg 1975; 54: 641–8.
Qvist TF, Skovsted P, Srensen MB. Moderate hypotensive anaesthesia for reduction of blood loss during total hip replacement. Acta Anaesthesiol Scand 1982; 26: 351–3.
Bernard JM, Pinaud M, Ganansia MF, Chatelier H, Souron R, Letenneur J. Systemic haemodynamic and metabolic effects of deliberate hypotension with isoflurane anaesthesia or sodium nitroprusside during total hip arthroplasty. Can J Anaesth 1987; 34: 135–40.
Thompson GE, Miller RD, Stevens WC. Hypotensive anesthesia for total hip arthoplasty: a study of blood loss and organ function (brain, heart, liver and kidney). Anesthesiology 1978; 48: 91–6.
Lam AM, Induced hypotension. Can Anaesth Soc J 1984; 31: S56–62.
Newens AF, Volz RG. Severe hypotension during prosthetic hip surgery with acrylic bone cement. Anesthesiology 1972; 36: 298–300.
Cohen CA, Smith TC. The intraoperative hazard of acrylic bone cement: report of a case. Anesthesiology 1971; 35: 547–9.
Modig J, Busch C, Olerud S, Saldeen T, Waernbaum G. Arterial hypotension and hypoxemia during total hip replacement: the importance of thromboplastic products, fat embolism and acrylic monomers. Acta Anaesthesiol Scand 1975; 19: 28–43.
Peebles DJ, Ellis RH, Stride SD, Simpson BR. Cardiovascular effects of methylmethacrylate cement. Br Med J 1972; 1:349–51.
Alexander JP. Clinical considerations in anaesthesia for hip arthroplasty. Anaesthesia 1978; 33: 748–51.
Michel R. Air embolism in hip surgery. Anaesthesia 1980; 35: 858–62.
Andersen KH. Air aspirated from the venous system during total hip replacement. Anaesthesia 1983; 38: 1175–8.
Modig J, Malmberg P. Pulmonary and circulatory reactions during total hip replacement surgery. Acta Anaesthesiol Scand 1975; 19: 219–37.
Tronzo RG, Kallos T, Wyche MQ. Elevation of intramedullary pressure when methylmethacrylate is inserted in total hip arthoplasty. J Bone Joint Surg 1974; 54: 714–8.
Jones RH. Physiologic emboli changes observed during total hip replacement arthoplasty. Clin Orthop 1975; 112: 192–200.
Kallos T. Impaired arterial oxygenation associated with the use of bone cement in the femoral shaft. Anesthesiology 1975; 42: 210–6.
Moskovitz PA, Ellenberg SS.Feffer HL et al. Low-dose heparin for prevention of venous thromboembolism in total hip arthroplasty and surgical repair of hip fractures. J Bone Joint Surg 1978; 60-A: 1065–70.
Modig J, Malmberg P, Karlstrom G. Effect of epidural versus general anaesthesia on calf blood flow. Acta Anaesthesiol Scand 1980; 24: 305–9.
Modig J, Borg T, Bagge L, Saldeen T. Role of extradural and of general anaesthesia in fibrinolysis and coagulation after total hip replacement. Br J Anaesth 1983; 55: 625–9.
Davis FM, Laurenson VG, Lewis J, Wells JE, Gillespie WJ. Metabolic response to total hip arthroplasty under hypobaric subarachnoid or general anaesthesia. Br J Anaesth 1987; 59: 725–9.
Hole A, Terjesen T, Breivik H. Epidural versus general anaesthesia for total hip arthroplasty in elderly patients. Acta Anaesthesiol Scand 1989; 24: 279–87.
Riis J, Lomholt B, Haxholdt O et al. Immediate and long-term mental recovery from general versus epidural anesthesia in elderly patients. Acta Anaesthesiol Scand 1983; 27: 44–9.
Johnson A, Bengtsson M, Merits H, Lofstrom JB. Anesthesia for major hip surgery. Reg Anaesth 1986; 11: 83–8.
Modig J. Respiration and circulation after total hip replacement surgery. Acta Anaesthesiol Scand 1976; 20: 225–36.
Catley DM, Thornton C, Jordan C, Lehane JR, Royston D, Jones JG. Pronounced, episodic desaturation in the postoperative period: its association with ventilatory pattern and analgesic regimen. Anesthesiology 1985; 63: 20–8.
Johnson R, Green JR, Charnley J. Pulmonary embolism and its prophylaxis following the Charnley total hip replacement. Clin Orthop 1977; 127: 123–32.
Author information
Authors and Affiliations
Rights and permissions
About this article
Cite this article
Covert, C.R., Fox, G.S. Anaesthesia for hip surgery in the elderly. Can J Anaesth 36, 311–319 (1989). https://doi.org/10.1007/BF03010771
Issue Date:
DOI: https://doi.org/10.1007/BF03010771