Fast‐track spinal anaesthesia reduces length of motor blockade and facilitates earlier discharge after joint arthroplasty

We read with interest the study protocol by Jensen et al.1 We applaud their effort in evaluating the mobility of patients within 6 h following surgeries in ambulatory total joint replacement, including total hip arthroplasty (THA), total knee arthroplasty (TKA), and unicompartmental knee arthroplasty after different types of anaesthesia. Herein, we would like to highlight that the evolution of spinal anaesthesia (SA) might impact the outcome of the study. There has been renewed interest in shorter acting local anaesthetics (LA) other than the traditional and ubiquitously used bupivacaine. These shorter acting LA have been used extensively for fast-track and ambulatory surgery programmes. Perhaps of greatest interest in the setting of SA for THA and TKA is mepivacaine. Several recent studies using spinal mepivacaine for THA and TKA have shown an earlier return of motor function and ambulation, shorter length of stay and decreased urinary retention compared with spinal bupivicaine.2-7 Early research on other short-duration LA of chloroprocaine and ropivacaine also showed promising outcomes.8, 9 Bupivacaine may be the least well-suited LA for fast-track arthroplasty. We believe it is comparable to using older, longer lasting general anaesthetics instead of our more rapidly eliminated general anaesthetic agents used in current practice. A few studies have examined using low doses of bupivacaine (3.5–5 mg) for TKA with favourable results on duration of SA.10, 11 These studies however did not examine THA whereby these lower doses may not produce adequate sensory and motor blockade for surgery.10, 11 As well some of these studies had significant analgesic supplementation or conversion to general anaesthesia (GA) with the low doses or utilised additional regional anaesthesia blockade with sciatic and femoral nerve blocks, which may further impede postoperative ambulation.10, 11 Further the formulation of bupivacaine, being either isobaric or hyperbaric can impact the duration of sensory and motor block. A recent meta-analysis has found the isobaric formulation to have a longer duration of both sensory and motor block.12 The cost associated with the anaesthetic technique, both in monetary terms and their impact on the environment, should also be considered. SA has been shown to reduce costs and is associated with a lower environmental impact when compared with volatile GA agents which are potent greenhouse gases.13, 14 This is particularly important as healthcare is one of the major contributors to greenhouse gas emissions and many healthcare systems are considering reducing carbon footprint such as our health services in Alberta, or moving towards net zero healthcare, for example, the National Health Services in the United Kingdom, as their priority. While many studies have recently emerged to investigate the differences between GA and SA in morbidity and mortality in THA/TKA, we congratulate the authors in taking this investigation from a different angle.1 Nonetheless, we would encourage researchers to consider using newer fast-track SA techniques for these studies, while taking into account of the duration of surgery. Other important considerations in terms of outcome measures include both the monetary perspective and planet health. All of the authors contibuted to this paper. None. I have no conflicts of interest to declare. Data sharing is not applicable – no new data generated.

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