We present a case of elective total knee arthroplasty where the surgical procedure was affected by the

neuromuscular blocking agent administered at induction of general anaesthesia. Recognition of this effect was vital

to avoid additional bone resection at the soft tissue balancing stage of the procedure

Holt, M

Lee, Paul

Journal of Arthritis

Paul YF Lee

Mark Holt

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The Effects of Neuromuscular Blocking Agents in Soft Tissue Balancing During Primary Total Knee Arthroplasty

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The Effects of Neuromuscular Blocking Agents in Soft Tissue Balancing DuringPrimary Total Knee ArthroplastyPaul YF Lee1* and Mark Holt21Welshbone, South Wales Orthopaedics Research Network, Wales, UK2Morrison Hospital, Swansea, Wales, UK*Corresponding author: Paul YF Lee, Welshbone, South Wales Orthopaedics Research Network, Wales, UK, Tel: +447764614688; E-mail: paul@welshbone.comRec date: May 11, 2016; Acc date: June 09, 2016; Pub date: June 13, 2016Copyright: © 2016 Lee PYF, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricteduse, distribution, and reproduction in any medium, provided the original author and source are credited.AbstractWe present a case of elective total knee arthroplasty where the surgical procedure was affected by theneuromuscular blocking agent administered at induction of general anaesthesia. Recognition of this effect was vitalto avoid additional bone resection at the soft tissue balancing stage of the procedure.Keywords: Total knee arthroplasty balancing; Neuromuscular;HypertensionCase ReportA 59 year old male with a medical history of hypertension, non-insulin dependent diabetes mellitus, angina and benign prostatichyperplasia whom underwent simultaneous bilateral primary totalknee arthroplasty surgery for osteoarthritis (Figure 1). The patientreceived Atracurium 50 mg IV at the induction of general anaesthesiafor muscle relaxant purposes.Figure 1: Patient’s left knee radiographs pre and immediately postoperationSurgery on the first side was uneventful, with soft tissues balancedusing conventional techniques. Surgery to the second kneecommenced upon closure of the first knee. Soft tissue balancing of theleft knee initially seemed uneventful. A 10 mm trial spacer was usedfor flexion and extension gap balancing and movements were normal.During preparation of the tibia, it was then noticed that the trialcomponents became increasingly difficult to remove, and after removalboth flexion and extension gaps had decreased significantly. At 1 hourand fifteen minutes post induction the knee gap had decreased suchthat it was not possible to remove the trial polyethylene spacer fromthe knee, the stage of the procedure was subsequently delayed.Figure 2: The anaesthetic chart used during the case presented. Afurther dose of atracurium is documented as given at 1345, 1 hourand fifteen minutes after induction of anaesthesiaA further 25 mg IV bolus of Atracurium (Figure 2) was then given.This enabled sufficient relaxation to enable soft tissue balancing tocontinue without difficulty. A 10 mm trial spacer was then used tocheck the gap and was put into the knee without problems encounteredbeforehand. The operation was finished as planned with a cementedtotal knee replacement and 10 mm polyethylene spacer (Figure 1).EUA post wound closure, and clinical evaluation at clinic follow uprevealed good collateral stability both in flexion and extension.Journal of Arthritis Lee and Holt, J Arthritis 2016, 5:3http://dx.doi.org/10.4172/2167-7921.1000202Case Report Open AccessJ ArthritisISSN:2167-7921 JAHS, an open access journalVolume 5 • Issue 3 • 1000202DiscussionSoft tissue management has a major influence on outcome inprimary total knee replacement [1]. It is therefore essential thatpossible sources for error in soft tissue balancing are eliminated. Wereport one such source of error, associated with the use of musclerelaxant during anaesthesia.At induction of anaesthesia, patients commonly receive a dose ofneuromuscular blocking drugs such as Atracurium, when having anendotracheal tube placed for the general anaesthetic [2,3].Neuromuscular blocking drugs such as atracurium block thetransmission through the neuromuscular junction at nicotinicreceptors and thus reduce skeletal muscle tone [2]. Non-depolarisingagents bind to receptors and prevent acetylcholine from stimulatingreceptors. Their effect is to compete with acetylcholine for nicotinicreceptors. Their blockade is competitive and therefore gradual in onset[2].Neuromuscular blocking drugs administered to patients during theinduction of anaesthesia prior to arthroplasty surgery are detailed inTable 1. A difference in their duration of action times is noted between5 and 40 minutes depending on the dose given [2-6].Muscle relaxant Dose (mg/kg) Duration of action (minutes)Atracurium 0.3-0.6 20-40Suxamethonium 1-2 5-10Vecuronium 0.08-0.1 15-30Rocuronium 0.6 30-40Table 1: Duration of action of muscle relaxants [4,6-8]Atracurium is a non-depolarising muscle relaxant. It is a short-acting relaxant, which is rapidly broken down by the body. This makesatracurium very predictable, as it wears off rapidly compared with thelonger-acting relaxants. A dose of 0.3-0.6 mg/kg will provide relaxationfor 20-40 minutes [3]. Depending on the nature of the surgery and thephysique of the patient, the return of muscle tone during surgery couldhave an effect on soft tissue tension [3,7]. Therefore, the return ofmuscle tone could theoretically affect the flexion and extension gapduring total knee replacement.When considered in terms of timing during primary totalarthroplasty, and in particular simultaneous bilateral primary totalarthroplasty or complex primary total arthroplasty of the knee, theupper limits of the duration of action are likely to coincide with thesoft tissue balancing of the knee.As the effect of the muscle relaxants administered diminishes,contraction of the knee may occur and significantly impede the softtissue balancing stage of the operation, in particular when balancingthe flexion and extension gaps. If this is not recognized it may lead toan unnecessary recut of the femur or tibia. These may then create anuneven soft tissue envelope around the implanted arthroplastycomponents and alter the long term outcome of the primaryarthroplasty procedure [1,8].ConclusionThe diminishing action of neuromuscular blockade may causecontraction of the knee during arthroplasty, which if unrecognised canlead to inappropriate bone resection. This should be understood byboth the surgeon and anaesthetist.We suggest surgical teams should be aware of the use ofneuromuscular blocking agents administered during primary kneearthroplasty operations and the timings of their duration of action asthis may coincide with crucial stages of the operation.Likewise, anaesthetic teams should appreciate the importance of thesoft tissue balancing in the outcome of primary total arthroplasty andshould be prepared to adjust the timings or give further doses ofneuromuscular blocking agents accordingly.References1. Peters CL (2006) Soft-tissue balancing in primary total knee arthroplasty.Instr Course Lect 55: 413-417.2. Allen M, Stashuk D, Doherty T, Kimpinski K, Rice C (2014)Neuromuscular remodeling and neuromuscular junction instability inhuman diabetic neuropathy (1168.1). The FASEB Journal.3. Varin F, Ducharme J, Theoret Y, Besner JG, Bevan DR, et al. (1990)Influence of extreme obesity on the body disposition and neuromuscularblocking effect of atracurium. Clin Pharm Ther 48: 18-25.4. Baillard C, Gehan G, Reboul-Marty J, Larmignat P, Samama CM, et al.(2000) Residual curarization in the recovery room after vecuronium. Br JAnaesth 84: 394-395.5. Martyn J, Durieux ME (2006) Succinylcholine: new insights intomechanisms of action of an old drug. Anesthesiology 104: 633-634.6. Vermeyen KM, Hoffmann VL, Saldien V (2003) Target controlledinfusion of rocuronium: analysis of effect data to select a pharmacokineticmodel. Br J Anaesth 90: 183-188.7. Peters CL, Jimenez C, Erickson J, Anderson MB, Pelt CE (2013) Lessonslearned from selective soft-tissue release for gap balancing in primarytotal knee arthroplasty: an analysis of 1216 consecutive total kneearthroplasties: AAOS exhibit selection. J Bone Joint Surg Am 95: e152.8. Lanting BA, Snider MG, Chess DG (2012) Effect of polyethylenecomponent thickness on range of motion and stability in primary totalknee arthroplasty. Orthopedics 35: e170-174. Citation: Lee PYF, Holt M (2016) The Effects of Neuromuscular Blocking Agents in Soft Tissue Balancing During Primary Total KneeArthroplasty. J Arthritis 5: 202. doi:10.4172/2167-7921.1000202Page 2 of 2J ArthritisISSN:2167-7921 JAHS, an open access journalVolume 5 • Issue 3 • 1000202

The effects of neuromuscular blocking agents in soft tissue balancing during primary total knee arthroplasty

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The effects of neuromuscular blocking agents in soft tissue balancing during primary total knee arthroplasty

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