C H A P T E R38 Anesthesia for Orthopedic Surgery Edward R. Mariano, MD, MAS KEY CONCEPTS 1 Clinical manifestations of bone cement platelet reactivity, attenuated postoperative implantation syndrome include hypoxia increase in factor VIII and von Willebrand (increased pulmonary shunt), hypotension, factor, attenuated postoperative decrease arrhythmias (including heart block and sinus in antithrombin III, and alterations in stress arrest), pulmonary hypertension (increased hormone release. pulmonary vascular resistance), and 6 For patients receiving prophylactic low- decreased cardiac output. molecular-weight heparin once daily, 2 Use of a pneumatic tourniquet on an neuraxial techniques may be performed (or extremity creates a bloodless field that neuraxial catheters removed) 10–12 h after greatly facilitates the surgery. However, the previous dose, with a 4-h delay before tourniquets can produce potential administering the next dose. problems of their own, including 7 Flexion and extension lateral radiographs hemodynamic changes, pain, metabolic of the cervical spine should be obtained alterations, arterial thromboembolism, preoperatively in patients with rheumatoid and pulmonary embolism. arthritis severe enough to require steroids, 3 Fat embolism syndrome classically presents immune therapy, or methotrexate. within 72 h following long-bone or If atlantoaxial instability is present, pelvic fracture, with the triad of dyspnea, intubation should be performed with inline confusion, and petechiae. stabilization utilizing video or fiberoptic laryngoscopy. 4 Deep vein thrombosis and pulmonary embolism can cause morbidity and 8 Effective communication between the mortality following orthopedic operations anesthesiologist and surgeon is essential on the pelvis and lower extremities. during bilateral hip arthroplasty. If major hemodynamic instability occurs during the 5 Neuraxial anesthesia alone or combined first hip replacement procedure, the second with general anesthesia may reduce arthroplasty should be postponed. thromboembolic complications by several mechanisms, including sympathectomy- 9 Adjuvants such as opioids, clonidine, induced increases in lower extremity venous ketorolac, and neostigmine when added to blood flow, systemic antiinflammatory local anesthetic solutions for intraarticular effects of local anesthetics, decreased —Continued next page 789 Use of bone cement dur. providing postoperative analgesia. Patients may present MANAGEMENT as neonates with congenital limb deformities. Emboli select orthopedic surgical procedures. The release of tissue thromboplastin may invasive approaches to knee and hip replacement. is fre- care issues specific to patients undergoing com. The cement mon orthopedic surgical procedures. early physical rehabilitation to maximize an interscalene block can supplement postoperative range of motion and prevent anesthesia and provide effective joint adhesions following knee replacement. Treatment strategies . Systemic absorption of plications. and cardiovascular instability as a erative management to facilitate overnight or even result of the circulation of vasoactive substances. cement. PERIOPERATIVE vider. such as minimally resistance. Anesthesia for most frequently occur during insertion of a femoral surgery on the spine is discussed in Chapter 27. or at any age with Bone Cement bone cancer. and knee operations. against the prosthetic components. Limb tourniquets limit blood loss but introduce leads to hardening of the cement and expansion additional risks. Orthopedic surgery challenges the anesthesia pro. The comorbidities of these patients vary widely based on age group. tion in the lungs. mias (including heart block and sinus arrest). the focus here on peri.790 SECTION III Anesthetic Management Continued— injection have been used in various 11 The interscalene brachial plexus block combinations to extend the duration of using ultrasound or electrical stimulation analgesia following knee arthroscopy. Mixing polymerized methylmethac- risk for venous thromboembolism following pelvic. polymethylmethacrylate. microthrombus forma- necessitating modifications in anesthetic and periop. The resultant Neuraxial and other regional anesthetic tech. Patients are at increased patient’s bone. It is impossible to cover the implantation syndrome include hypoxia anesthetic implications of diverse orthopedic opera. interdigitates within the interstices of cancellous patients with long bone fractures are predisposed bone and strongly binds the prosthetic device to the to fat embolism syndrome. arrhyth- tions in one chapter. postoperative analgesia. This chapter focuses on perioperative Bone cement. quently required for joint arthroplasties. air into venous channels. and incidence of perioperative thromboembolic com. pulmo- operative management considerations and strategies nary hypertension (increased pulmonary vascular for the anesthetic management of patients undergoing resistance). hence. of the polymer chains. vasodilation and a decrease in systemic vascular Advances in surgical techniques. 10 Effective postoperative analgesia facilitates Even when general anesthesia is employed. monomer causes polymerization and cross-linking ing arthroplasties can cause hemodynamic instabil. rylate powder with liquid methylmethacrylate hip. and decreased cardiac output. same-day discharge of patients who formerly required 1 The clinical manifestations of bone cement days of hospitalization. is ideally suited for shoulder procedures. hypotension. as CONSIDERATIONS IN teenagers with sports-related injuries. intramedullary hypertension (>500 mm Hg) can niques play an important role in decreasing the cause embolization of fat. and residual methylmethacrylate monomer can produce facilitating early rehabilitation and hospital discharge. bone marrow. (increased pulmonary shunt). This exothermic reaction ity. as adults for ORTHOPEDIC SURGERY procedures ranging from excision of minor soft- tissue mass to joint replacement. For example. prosthesis for hip arthroplasty. are trigger platelet aggregation. Inflation temperature decreases. despite a regional block that the prosthesis over time. ing leg exsanguination. ment of deep venous thrombosis. and following tourniquet deflation. CHAPTER 38 Anesthesia for Orthopedic Surgery 791 for this complication include increasing inspired Awake patients predictably experience tour- oxygen concentration prior to cementing. healthy active mately 1 h after cuff inflation. These meta- may produce rhabdomyolysis or permanent periph. Even during are made of a porous material that allows natural general anesthesia. The likelihood of Therefore. rarely. becomes so severe over time that patients may Another source of concern related to the use require substantial supplemental analgesia. Tourniquet inflation has also ventilation in the spontaneously breathing patient been associated with increases in body temperature and. and diaphoresis. and surgical technique. The mechanism and neural pathways performing high-pressure lavage of the femoral shaft for this severe aching and burning sensation defy to remove debris (potential microemboli). depending on the joint anesthetic block. bilateral lower extremity exsan. including hemodynamic a precipitous decrease in central venous and arterial changes. Heart rate usually increases and core boembolism. (“intensity” of block). or using precise explanation. sion. bolic alterations can cause an increase in minute eral nerve damage. In fact. Tourniquets . after tourniquet inflation. Prolonged inflation (>2 h) routinely leads (Paco2). end-tidal carbon dioxide (Etco2). few minutes. Practices thetic technique (regional anesthesia versus general continue to evolve regarding selection of cemented anesthesia). if not of cement is the potential for gradual loosening of general anesthesia. Although not usually ventricle) following tourniquet deflation even in clinically important. niquet pain with inflation pressures of 100 mm ing to maintain euvolemia. stimulus from tourniquet com- bone to grow into them. arrhythmias. tricles and diastolic dysfunction. extent of dermatomal spread of regional versus cementless implants. Washout of accumulated pressure is usually set approximately 100 mm Hg metabolic wastes in the ischemic extremity increases higher than the patient’s baseline systolic blood partial pressure of carbon dioxide in arterial blood pressure. arterial throm. Transesophageal Exsanguination of a lower extremity and tour. cemented prostheses are preferred for tourniquet pain and its accompanying hypertension older (>80 years) and less active patients who often may be influenced by many factors. metabolic alterations. Cementless prostheses pression often manifests as a gradually increasing generally last longer and may be advantageous for mean arterial blood pressure beginning approxi- younger. echocardiography can detect subclinical pulmonary niquet inflation cause a rapid shift of blood volume embolism (miliary emboli in the right atrium and into the central circulation. monitor. active patients. including anes- have osteoporosis or thin cortical bone. Tourniquet pain gradually a femoral component that does not require cement. sion. pain. minor cases such as diagnostic knee arthroscopy. tourniquets can produce poten. 2 Use of a pneumatic tourniquet on an extremity Cuff deflation invariably and immediately creates a bloodless field that greatly facilitates relieves tourniquet pain and associated hyperten- surgery. cuff deflation may be accompanied by tial problems of their own. choice of local anesthetic and dose affected. blood pressure. and pulmonary embolism. Newer cementless implants is adequate for surgical anesthesia. patient. and supplementation with adjuvants either intravenously or in combination Pneumatic Tourniquets with local anesthetic solutions when applicable. However. Tourniquet-induced isch- in pediatric patients undergoing lower extremity emia of a lower extremity may lead to the develop- surgery. tachycardia. Signs of progressive bone formation is required and recovery may be sympathetic activation include marked hyperten- longer compared to cemented joint replacements. however. and to transient muscle dysfunction from ischemia and serum lactate and potassium levels. guination can cause an increase in central venous Rare episodes of massive pulmonary embolism dur- pressure and arterial blood pressure that may not ing total knee arthroplasty have been reported dur- be well tolerated in patients with noncompliant ven. creating a vent hole in Hg above systolic blood pressure for more than a the distal femur to relieve intramedullary pressure. hypertension. drome (ARDS. and conjunctiva. ischemic-appearing ST-segment changes and a pat- bia. include venous stasis with hypercoagulable state due Coagulation abnormalities such as thrombocyto. agitation. Deep Venous Thrombosis native theory proposes that the fat globules are & Thromboembolism chylomicrons resulting from the aggregation of cir- 4 Deep vein thrombosis (DVT) and pulmonary culating free fatty acids caused by changes in fatty embolism (PE) can cause morbidity and mor- acid metabolism. upper extremities. with the triad of strategies in the event of ARDS. arterial oxygen saturation and a rise in pulmonary ease. ally present. mechanical thromboprophylaxis should be consid- fuse pulmonary opacities.792 SECTION III Anesthetic Management have been safely used in patients with sickle cell dis. Patients at greatest risk include those undergoing festations (eg. the tality following orthopedic operations on the pelvis increased free fatty acid levels can have a toxic effect and lower extremities. with continuous positive airway pressure ventila- 3 It classically presents within 72 h following tion to prevent hypoxia and with specific ventilator long-bone or pelvic fracture. laxis. This syndrome sion will require appropriate pressor support. Risk factors include obesity. Electrocardiography may show maintaining oxygenation. vasodilators may aid the management of pulmonary tation. although particular attention should be paid to artery pressures. fracture. use of a tourniquet. The most popular theory for its pathogenesis not supported by randomized clinical trials. the use of pharmacological and symptoms of fat embolism syndrome occur 1–3 anticoagulants must be balanced against the risk of days after the precipitating event. parental feeding with lipid infusion. While respiratory failure with radiographic findings of dif. Serum lipase activity may be elevated Pharmacological prophylaxis and the routine but does not predict disease severity. or coma) hip surgery and knee replacement or major opera- are the probable result of capillary damage in the tions for lower extremity trauma. confusion. and normothermia. An alter. Fat embolism syndrome is Supportive treatment consists of oxygen therapy less frequent but potentially fatal (10–20% mortality). or sputum. and can also be seen following cardiopulmonary resusci. and lipo. stupor. Fat globules occasionally 1–3%. Neurological mani. on the capillary–alveolar membrane leading to the age greater than 60 years. procedures lasting more release of vasoactive amines and prostaglandins and than 30 min. normocarbia or hypocar. Pulmonary use of mechanical devices such as intermittent pneu- involvement typically progresses from mild hypoxia matic compression (IPC) have been shown to and a normal chest radiograph to severe hypoxia or decrease the incidence of DVT and PE. Regardless of their source. signs may include a decline in Etco2 and DVT but having “normal” bleeding risk. all long-bone fractures. holds that fat globules are released by the disruption of fat cells in the fractured bone and enter the circu- lation through tears in medullary vessels. Management is two-fold: preventative and sup- portive. The incidence of clinically important PE fol- The diagnosis of fat embolism syndrome is sug. reduces the risk of pulmonary complications. These signs experience DVT rates of 40–80% without prophy- may be exacerbated by hypoxia. hydration. be as high as 20%. Underlying pathophysiological mechanisms may be observed in the retina. For patients at increased risk for anesthesia. and petechiae. see Chapter 57). Early stabilization of the fracture decreases Fat Embolism Syndrome the incidence of fat embolism syndrome and. tern of right-sided heart strain. to localized and systemic inflammatory responses to penia or prolonged clotting times are occasion. and immobilization for more than 4 days. in par- Some degree of fat embolism probably occurs with ticular. urine. confusion. surgery. Systemic hypoten- dyspnea. whereas that of fatal PE may be axillae. Such patients will cerebral circulation and cerebral edema. Most of the classic signs ered for every patient. High-dose corticosteroid therapy is suction. lower extremity the development of acute respiratory distress syn. During general major bleeding. low-dose . lowing hip surgery in some studies is reported to gested by petechiae on the chest. and particular orthopedic surgeon’s routine. ters (see Suggested Reading). fracture of up to 10% during the initial hospital- According to the Third Edition of the American ization and over 25% within 1 year. Performance of (subcapital. guidelines occur regularly. pulmonary congestion (and effusion) dose. that may. clopidogrel. before the first dose of LMWH. blood loss may be significant. further compromis- ceptable risk for spinal or epidural hematoma fol. suggests that these recommendations be applied to farin. ial catheters removed) 10–12 h after the previous other factors can include bibasilar atelectasis from dose. cerebrovascular disease. closed reduction of hip dislocation. attenuated postoperative increases in and elderly. intertrochanteric. CHAPTER 38 Anesthesia for Orthopedic Surgery 793 subcutaneous unfractionated heparin (LUFH). With twice-daily dosing. intracapsular lowing neuraxial anesthesia. there fractures (Figure 38–1). the guidelines vary based on regimen. or diabetes. The Third Edition of the guidelines also ated for hip fracture surgery. subtrochanteric) when the total daily dose is 10. Most patients presenting for hip fractures are frail let reactivity. war. A normal or borderline- are no data on the safety of neuraxial anesthesia low preoperative hematocrit may be deceiving when hemoconcentration masks occult blood loss. With once-daily dosing. and Patients presenting with hip fractures are fre- intravenous glycoprotein IIb/IIIa inhibitors). 5 Neuraxial anesthesia alone or combined with general anesthesia may reduce thromboem- bolic complications by several mechanisms. transcervical) fractures are associated neuraxial block (or removal of a neuraxial catheter) with less blood loss than extracapsular (base of the is not contraindicated with subcutaneous LUFH femoral neck. throm. systemic antiinflam. These FRACTURE OF THE HIP include sympathectomy-induced increases in lower extremity venous blood flow. ing may be managed with mechanical prophylaxis alone until bleeding risk decreases. Many of these Society of Regional Anesthesia and Pain Medicine patients have concomitant diseases such as coro- Evidence-Based Guidelines on regional anesthesia nary artery disease. In general. and Studies have reported mortality rates following hip alterations in stress hormone release. anti- coagulants are started the day of surgery in patients Hip Surgery without indwelling epidural catheters. Depending on the site of the hip fracture. patients currently receiving obstructive pulmonary disease.000 units or less. or consolidation due should not be left in situ and should be removed 2 h to infection. decreased plate. The choice between regional (spinal or epidural) and catheters should be removed when the INR is and general anesthesia has been extensively evalu- 1. An occasional young patient will have factor VIII and von Willebrand factor. total hip arthroplasty. be due to fat embolism. fondaparinux. For patients Another characteristic of hip fracture patients receiving prophylactic LMWH. bolytics. Warfarin may Common hip procedures performed in adults inc- be started the night before surgery depending on the lude repair of hip fracture. is the frequent presence of preoperative hypoxia neuraxial techniques may be performed (or neurax. direct thrombin inhibitors. 6 when larger doses are given.5 or lower. A meta-analysis of . neuraxial catheters from congestive heart failure. chronic and anticoagulation. postoperative decreases in antithrombin III. antiplatelet agents (eg. occult or therapeutic regimens of LMWH present an unac. Patients at significantly increased risk of bleed. In general. ing intravascular volume. Preoperative Considerations matory effects of local anesthetics. or low-molecular-weight heparin (LMWH) deep peripheral nerve and plexus blocks and cathe- may be employed in addition to mechanical prophy. with a 4-h delay before administering the next immobility. ticlopidine. quently dehydrated from inadequate oral intake. at least in part. Patients on warfarin therapy should not receive a neuraxial block unless Intraoperative Management the international normalized ratio (INR) is normal. attenuated sustained major trauma to the femur or pelvis. Revisions to these laxis. hypobaric or iso. one should secure sufficient venous femur may be treated with percutaneous pinning access to permit rapid transfusion. They are usually performed with patients in reduction and fixation to be used. degree of displacement. hemiarthroplasty. longer. and surgeon hemodynamic changes. Therefore. Surgical treatment baric local anesthesia facilitates positioning since of extracapsular hip fractures is accomplished with the patient can remain in the same position for both either an extramedullary implant (eg. . require internal fixation.794 SECTION III Anesthetic Management Subcapital Intertrochanteric Transcervical Base of neck Subtrochanteric FIGURE 381 Blood loss from hip fracture depends on the location of the fracture (subtrochanteric. sliding screw block placement and surgery. greater blood loss. more invasive operations than other proce- Consideration should also be given to the type of dures. Displaced intracapsular fractures may additional advantage of postoperative pain control. preop. or total If a spinal anesthetic is planned. 15 randomized clinical trials showed a decrease in postoperative DVT and 1-month mortality with regional anesthesia. Intrathecal opioids and plate) or intramedullary implant (eg. hip replacement (Figure 38–2). Undisplaced fractures of the proximal used. particularly if cement is preference. provides the fractures. with or with. result in greater erative functional status of the patient. This is dependent the lateral decubitus position. nail). potentially. Gamma such as morphine can extend postoperative analge. and. subcapital) because the capsule restricts blood loss by acting like a tourniquet. sia but require close postoperative monitoring for Hemiarthroplasty and total hip replacement are delayed respiratory depression. intertrochanteric > base of femoral neck > transcervical. are associated with on the fracture site. persist beyond 3 months. plate are most often employed for intertrochanteric out concomitant general anesthesia. but these advantages do not FIGURE 382 Uncemented total hip arthroplasty. A hip compression screw and side A neuraxial anesthetic technique. The incidence of postop- erative delirium and cognitive dysfunction may be lower following regional anesthesia if intravenous or cannulated screw fixation with the patient in the sedation can be minimized. supine position. neck manipulation can limit jaw mobility and range of motion to such a during tracheal intubation should be minimized to degree that conventional orotracheal intubation may avoid nerve root compression or disc protrusion. invasive arterial monitoring may be justified Hematopoietic Anemia. Extreme cases of RA involve almost all synovial membranes. CHAPTER 38 Anesthesia for Orthopedic Surgery 795 TOTAL HIP ARTHROPLASTY protrusion of the odontoid process into the foramen magnum during intubation. bleeding. have serious side effects such as gastrointestinal nulation can be challenging. or is a degenerative disease affecting the articular sur. The etiology of osteoarthritis appears to stabilization utilizing video or fiberoptic laryngos- involve repetitive joint trauma. including positioning of the patient (usu- ally in the lateral decubitus position). compromising vertebral Preoperative Considerations blood flow and compressing the spinal cord or brain- Most patients undergoing total hip replacement suffer from osteoarthritis (degenerative joint dis- 7 stem (Figure 38–3). immune therapy. dislocation and removal of the femoral head. RA often affects the small joints of receive nonsteroidal antiinflammatory drugs the hands. and feet causing severe deformity. copy. may lead to cal steps. If atlantoaxial instability is present. eosinophilia. platelet for select patients undergoing these procedures. and venous thromboembolism. impaired immune system A.and postop- Pulmonary Pleural effusion. cricoarytenoid arthritis. Hip Resurfacing Arthroplasty The increasing number of younger patients presenting Dermatological Thin and atrophic skin from the disease for hip arthroplasty and of other patients who require and immunosuppressive drugs revision of standard (metal-on-polyethylene) total . without cement). RA is a smaller diameter tracheal tube has been used. Osteoarthritis enough to require steroids. Endocrine Adrenal insufficiency (from glucocorticoid therapy). These drugs can when this occurs. intravenous and radial artery can. THR is also associated with three conduction defects. coronary arteritis. wrists. Because osteoarthri. and platelet dysfunction. as opposed to the postextubation airway obstruction even when a articular wear and tear of osteoarthritis. Atlantoaxial subluxation. Total hip replacement (THR) involves several surgi- which can be diagnosed radiologically. face of one or more joints (most commonly the hips tracheal intubation should be performed with inline and knees). This condition may lead to mation of synovial membranes. pulmonary nodules. ral head and stem) into the femoral shaft (with or myocarditis. be impossible. Involvement of the temporomandibular joint tis may also involve the spine. methotrexate. intra. reaming of the TABLE 381 Systemic manifestations of rheumatoid arthritis. and reaming of the Organ System Abnormalities femur and insertion of a femoral component (femo- Cardiovascular Pericardial thickening and effusion. renal toxicity. dysfunction (from aspirin therapy). including those in the cervical spine and Intraoperative Management temporomandibular joint. interstitial pulmonary fibrosis Thus. Flexion and extension lat- eral radiographs of the cervical spine should be ease). acetabulum and insertion of a prosthetic acetabular cup (with or without cement). (NSAIDs) for pain management. Hoarseness or inspiratory stridor may RA is characterized by immune-mediated joint signal a narrowing of the glottic opening caused by destruction with chronic and progressive inflam. autoimmune conditions such as rheumatoid obtained preoperatively in patients with RA severe arthritis (RA). Neuraxial administration of opioids such as mor- thrombocytopenia phine in the perioperative period extends the dura- tion of postoperative analgesia. cardiac potentially life-threatening complications: bone valve fibrosis (aortic regurgitation) cement implantation syndrome. erative hemorrhage. systemic disease affecting multiple organ systems Patients with RA or osteoarthritis commonly (Table 38–1). vasculitis. or avascular necrosis. Surgical approaches can be anterolateral patient satisfaction. finding that patients who undergo resurfacing are cally providing greater preservation of the blood sup. particularly in women. the presence of metal debris in the joint space . Compared gait or postural balance at 3 months postoperatively. note the severe in patients with severe rheumatoid arthritis. Finally. A recent meta-analysis favored resurfacing in terms facing maintains patients’ native bone to a greater of functional outcome and blood loss despite com- degree. Of particular concern is the or posterior. lateral radiographs are mandatory of a patient with rheumatoid arthritis. those receiving traditional hip arthroplasty. with traditional hip arthroplasty implants. nearly twice as likely to require revision surgery as ply to the femoral head. A: Radiograph C1–C2 instability. Metal-on-metal hybrid implants are usually parable results for postoperative pain scores and employed. There is patients are placed in the lateral decubitus position a higher incidence of aseptic component loosening similar to traditional hip arthroplasty. (possibly from metal hypersensitivity) and femo- Outcomes data related to hip resurfacing versus ral neck fracture. hip arthroplasty implants has led to redevelopment Prospective studies have not shown a difference in of hip resurfacing arthroplasty techniques. B: Lateral cervical spine may be asymptomatic.796 SECTION III Anesthetic Management A B FIGURE 383 Because instability of the cervical spine of a normal lateral cervical spine. traditional total hip arthroplasty are controversial. with the posterior approach theoreti. hip resur. With the posterior approach. Tracking with general anesthesia even at similar mean arte. or magnetic reso- studies suggest that blood loss may be decreased nance imaging. Some roscopy. Alternatively (and more expensively). Revision Arthroplasty through minimally invasive techniques employ- Revision of a prior hip arthroplasty may be associated ing cementless implants. The mechanism is unclear. If major hemodynamic replacement surgery reduces blood loss. of bone and soft tissue based on radiographs. Preoperative administration of vitamins narrowing of indications for the prostheses and the (B12 and K) and iron can treat mild forms of chronic procedure. accurately reconstruct three-dimensional images cedure. spinal or epidural anesthesia) compared the patient on the operating room table. CAS tion and intraoperative blood salvage should be thus allows accurate placement of implants through 3-in. and the navi- Because the likelihood of perioperative blood trans. computed tomography. munication between the anesthesia provider Maintaining normal body temperature during hip and surgeon is essential. The computer matches preoperative during hip surgery if a regional anesthesia technique images or planning information to the position of is used (eg. Blood loss depends on many factors. incision Tracking devices FIGURE 384 Minimally invasive total hip arthroplasty: lateral approach. Computer software can with much greater blood loss than in the initial pro. Computer-assisted surgery (CAS) may improve surgical outcomes and promote early rehabilitation C. Monitoring production by stimulating the division and differen- 8 may include echocardiography. Bilateral Arthroplasty subcutaneously weekly beginning 21 days before Bilateral hip arthroplasty can be safely performed in surgery and ending on the day of surgery) may also fit patients as a combined procedure. the second arthroplasty should be D. light-emitting diodes to sense their positions. assuming the decrease the need for perioperative allogeneic blood absence of significant pulmonary embolization after transfusion. . Erythropoietin increases red blood cell insertion of the first femoral component. recombinant human erythropoietin (600 IU/kg B. and instruments used during surgery. Effective com. instability occurs during the first hip replacement procedure. Minimally Invasive Arthroplasty postponed. tiation of erythroid progenitors in the bone marrow. Note the small 3-in. anemia. incision and tracking devices for the CAS navigation system. preoperative autologous blood dona. fluo- ing the experience and skill of the surgeon. includ. gation system utilizes optical cameras and infrared fusion is high. devices are attached to target bones (Figure 38–4) rial blood pressures. CHAPTER 38 Anesthesia for Orthopedic Surgery 797 (from metal-on-metal contact) has led to a marked considered. Techniques that avoid large doses may be corrected with closed reduction facilitated by of systemic opioids have obvious appeal. There is a 3% incidence of hip dislocation following for ambulatory surgery. if necessary. ace. knee Anesthetic techniques should promote rapid recov. . vacaine) usually provide satisfactory analgesia for to facilitate the reduction when the hip musculature is severely contracted. two separate 2-in. thought of as being a healthy young athlete. gabapentin. but evidence is lacking lar injections. Hip Arthroscopy Intraoperative Management In recent years. incision with the patient in the lateral decubitus Arthroscopy has revolutionized surgery of many position (Figure 38–4). Fortunately. However. performed as outpatient procedures. patients with hip implants require special precautions dur. ankle. an anterior approach utilizes joints. periarticu- port hip arthroscopy for FAI. solutions for intraarticular injection have been used in various combinations to extend the duration of Knee Surgery analgesia. or intraarticular injections employing for other indications. internal rotation. ketorolac. clonidine. The surgery is per- such as femoroacetabular impingement (FAI). and osteoarthritis. Alternative anesthetic tech- erature (small. The lateral approach utilizes a single Preoperative Considerations 3-in. and the resulting reduction in tissue KNEE ARTHROSCOPY and muscle damage could lead to less pain and early rehabilitation. Successful reduction should 9 several hours postoperatively. neuraxial anesthesia. hip arthroscopy has increased in A bloodless field greatly facilitates arthroscopic sur- popularity as a minimally invasive alternative to gery. use of a brief general anesthetic. local anesthetic solutions with or without adjuvants combined with intravenous sedation. there is fair evidence in the published lit. and wrist. shoulder. in a supine position under general anesthesia or At present. knee surgery lends itself to the open arthrotomy for a variety of surgical indications use of a pneumatic tourniquet. and minimal nau- tion increase the risk of dislocation. CLOSED REDUCTION success and patient satisfaction appear to be equal OF HIP DISLOCATION between epidural and spinal anesthesia. force is required to dislocate a prosthetic hip. Although the nent) with the patient supine. Postoperative Pain Management ing positioning for subsequent surgical procedures. time to discharge following primary hip arthroplasty and a 20% incidence fol. Joint arthroscopies are usually component and another for the femoral compo. adequate pain relief. loose bodies. neuraxial anesthesia may be prolonged compared lowing total hip revision arthroplasty. including the hip. be confirmed radiologically prior to the patient’s and neostigmine when added to local anesthetic emergence. randomized controlled trials) to sup. Other multimodal pain management strategies include systemic NSAIDs. Successful outpatient recovery depends on early Extremes of hip flexion. The two most frequently performed knee surgeries and single or continuous peripheral nerve blocks for are arthroscopy and total or partial joint replacement. E. incisions (one for the acetabular elbow. Comparing neuraxial anesthesia techniques. niques include peripheral nerve blocks. Hip dislocations sea and vomiting. formed as an outpatient procedure with the patient tabular labral tears. knee.798 SECTION III Anesthetic Management small incisions. epinephrine. Because less with general anesthesia. Adjuvants such as opioids. Temporary paraly- Intraarticular local anesthetics (bupivacaine or ropi- sis can be provided by succinylcholine. Minimally invasive typical patient undergoing knee arthroscopy is often techniques can reduce hospitalization to 24 h or less. total intravenous general anesthesia. and adduc- ambulation. arthroscopic ligament reconstruction. arthroscopies are frequently performed in elderly ery and can include neuraxial regional anesthesia or patients with multiple medical problems. . emboli into the systemic circulation may exaggerate any tendency for hypotension following tourniquet Intraoperative Management release. and intraoperative blood loss or perineural catheter can be very helpful in B A FIGURE 385 Total (A) and partial (B) knee replacement. RA. during hip arthroplasty. patients remain Preoperative placement of a lumbar epidural in a supine position. During total knee arthroplasty. Subsequent release of osteoarthritis). Cooperative patients usually tolerate a neuraxial anesthetic Preoperative Considerations technique with intravenous sedation. CHAPTER 38 Anesthesia for Orthopedic Surgery 799 TOTAL KNEE REPLACEMENT is limited by the use of a tourniquet. Bone cement Patients presenting for total knee replacement implantation syndrome following insertion of a (Figure 38–5) have similar comorbidities to femoral prosthesis is possible but is less likely than those undergoing total hip replacement (eg. It is impor. SHOULDER SURGERY Shoulder operations may be open or arthroscopic. control and facilitate early rehabilitation. The beach chair position may be associated with decreases in cerebral perfusion as FIGURE 386 A “block room” can be located measured by tissue oximetry. techniques may reduce quadriceps muscle damage. continuous peripheral ments. or continuous peripheral nerve blocks. subacro- mial impingement or rotator cuff tears). Partial knee replacement (unicompartmental those involving patient falls are of greatest con- or patellofemoral) and minimally invasive knee cern. traumatic fractures. which is typically and ambulation goals. invasive blood pressure monitoring. rheumatoid arthritis). nerve entrapment syndromes (eg. cases of blindness. total knee arthroplasty. postanesthesia care unit and should offer standard monitoring (as outlined by the American Society of emphasizing the need to accurately measure blood Anesthesiologists) and ample storage for regional pressure at the level of the brain. cal therapy. The management of peri- nausea and vomiting. or ortho. and physi- and ensure that patients receive this beneficial anal. Among the complications of lower gesic technique (Figure 38–6). When using non- anesthesia supplies and equipment. These procedures are performed either in a sitting (“beach chair”) or. can provide target-specific pain and cooperative patient during physical therapy. facilitating earlier achievement of range-of-motion Surgery on the Upper Extremity Procedures on the upper extremities include those for disorders of the shoulder (eg. Effective postoperative analgesia facil. Preoperative placement in and can be incorporated into integrated clinical a “block room” can prevent operating room delays pathways involving surgery. and joint arthroplasties (eg.800 SECTION III Anesthetic Management managing postoperative pain. car- pal tunnel syndrome). or stroke. extremity perineural local anesthetic infusions. urinary retention. in a preoperative holding area. and even brain death have been described. lumbar nerve block catheters with subsequent perineu- epidural and femoral perineural catheters provide ral local anesthetic infusions have been shown equivalent analgesia while femoral perineural to decrease time to meet discharge criteria for catheters produce fewer side effects (eg. the lateral decu- bitus position. therapy is arranged. Anesthetic management and itates early physical rehabilitation to maximize postoperative analgesia should accommodate and postoperative range of motion and prevent joint facilitate the accelerated recovery schedule. alone or tant to balance pain control with the need for an alert in combination. nursing. neural catheters takes a hands-on team approach static lightheadedness). these employed. With strict patient selection. less commonly. and comprehensive fall prevention programs arthroplasty with muscle-sparing approaches have need to be in place wherever these techniques are been described. For unilateral knee replacement. pruritus. and may allow for discharge more severe than pain following hip replacement within 24 h following surgery if outpatient physical 10 surgery. Single adhesions following knee replacement. induction room. In ran- Epidural analgesia is useful in bilateral knee replace. domized clinical trials. the cuff should . and the operating room table rotated 90° to Chapter 46). The patient has operations of the hand (eg. or facilitate physical therapy. an interscalene block can supple. If chial plexus block is the preferred regional anesthetic a surgeon requests controlled hypotension. planned surgical site and location of the pneumatic 11 The interscalene brachial plexus block using tourniquet. surgeons may insert a position the operative arm in the center of the room. CHAPTER 38 Anesthesia for Orthopedic Surgery 801 be applied on the upper arm because systolic blood For operations lasting more than 1 h or more pressure readings from the calf can be 40 mm Hg invasive procedures involving bones or joints. same-day discharge. CASE DISCUSSION DISTAL UPPER Managing Blood Loss in Jehovah’s Witnesses EXTREMITY SURGERY A 58-year-old Jehovah’s Witness presents for Distal upper extremity surgical procedures generally hemipelvectomy to resect a malignant bone take place on an outpatient basis. tourniquet tolerance. patient has no other medical problems. Multimodal analgesia. Even when general anes. carpal tunnel release) of received chemotherapy over the last 2 months short duration may be performed with local infiltra- with multiple drugs. Alternatively. Multiple approaches can be used to anes- rial catheter for invasive blood pressure monitoring thetize the brachial plexus for distal upper extrem- is recommended. and the transducer should be ity surgery (see Chapter 46). including sys. including doxorubicin. hence. Preoperative insertion of an indwelling peri. venting severe postoperative pain and nausea (see ommended. Intense muscle relaxation is usually tribution (arising from the dorsal rami of T1 and required for major shoulder surgery during general sometimes T2). The tion or with intravenous regional anesthesia (IVRA. the brainstem (external meatus of the ear). perioperative management humeral chondrolysis in retrospective human and should focus on ensuring rapid emergence and pre- prospective animal studies and is not currently rec. Continuous peripheral ultrasound or electrical stimulation is ideally nerve blocks may be appropriate for inpatient and suited for shoulder procedures. can help reduce postoperative opioid requirements. an arte. Anesthetic considerations for distal upper neural catheter with subsequent infusion of a extremity surgery should include patient position- dilute local anesthetic infusion solution allows ing and use of a pneumatic tourniquet. the fixed-reservoir disposable pumps following operative arm abducted 90° and resting on a hand arthroscopic or open shoulder operations (see table. Because patients are often scheduled for has been associated with postarthroscopic gleno. and the or Bier block). . The supraclavicular select outpatient procedures to extend the duration approach also can be used. The limiting factor with IVRA is preoperative hematocrit is 47%. temic NSAIDs (if no contraindications) and local anesthetic infusions in the perioperative period. plexus block technique should take into account the ably. the elbow. Chapter 44). subacromial catheter to provide continuous infu. Brachial plexus blocks ment anesthesia and provide effective postoperative do not anesthetize the intercostobrachial nerve dis- analgesia. particularly when not combined with a of local anesthetic may be required for procedures brachial plexus block. involving the medial upper arm. subcutaneous infiltration anesthesia. Most proce- postoperative analgesia for 48–72 h with most dures can be performed with the patient supine. prefer. and certain operations may require the Direct placement of intraarticular catheters into the patient be in lateral decubitus or even prone posi- glenohumeral joint with infusion of bupivacaine tion. a bra- higher than brachial readings on the same patient. if applicable. Selection of brachial positioned at least at the level of the heart or. of analgesia further into the postoperative period thesia is employed. Exceptions to this rule often involve surgery around sion of local anesthetic for postoperative analgesia. technique. Minor soft tissue tumor (osteogenic sarcoma). They accept crystalloids. as long as their blood main. extreme degrees of anemia. Augmentation of stroke volume increases cardiac output. would be indicated in most patients undergoing cal reasons (eg. In a Jehovah’s what is done to them. Invasive arterial blood their interpretation of the Bible (“to keep abstain.802 SECTION III Anesthetic Management How does the care of Jehovah’s How would the inability to transfuse blood Witnesses particularly challenge the affect intraoperative monitoring decisions? anesthesiologist? Hemipelvectomy involves radical resection Jehovah’s Witnesses.” Acts 15:28. Coronary and cerebral blood flows removed from the body should be discarded (“You increase in the absence of coronary artery disease should pour it out upon the ground as water. The risk of cardio- during surgery. object to the administration of larly true for large tumors removed using the more blood for any indication. Witnesses often and the absence of preexisting major end-organ view albumin. hetastarch. a fellowship of more than that can lead to massive blood loss. Physicians are this procedure. Thus. allowing arterial Do they allow the use of autologous blood? blood pressure and heart rate to remain relatively According to their religion. fresh frozen What physiological effects result from severe plasma. gen extraction. Techniques that minimize intra- obliged to honor the principle of autonomy. upholds that patients have final authority over aprotinin) should be considered. Oozing from surgical wounds as a tion and storage would not be allowed. Techniques result of dilutional coagulopathy may accompany of acute normovolemic hemodilution and intraop. and hemophiliac surprisingly well. and oxygen consumption. immune globulins. Continuous electrocardiographic Which intravenous fluids will Witnesses ST-segment analysis may signal myocardial accept? ischemia. mia (Hb <5 g/dL) may be improved by monitor- sequences of blood refusal.29) and not for medi. most patients tolerate severe anemia of albumin). which operative blood loss (eg. platelets) but not non–blood-containing anemia? solutions. For example. and Assuming the maintenance of normovolemia dextran replacement solutions. . What are some of the anesthetic implications of tains continuity with their circulatory systems at all preoperative doxorubicin therapy? times. This objection stems from invasive internal approach. A decrease in venous Deuteronomy 12:24) and not stored. the fear of hepatitis). any blood that is unchanged. erythropoietin (because of the use dysfunction. controlled hypotension. blood. the oxygen saturation reflects an increase in tissue oxy- usual practice of autologous preoperative collec. Witnesses typically sign a Witness. pressure and central venous pressure monitors ing from . up to 4 units of blood could be This anthracycline chemotherapeutic agent drawn from the patient immediately before surgery has well-recognized cardiac side effects. ing cardiac output. oxygen delivery. packed red blood cells.” and carotid artery stenosis. Decreased blood viscosity and preparations as a gray area that requires a personal vasodilation lower systemic vascular resistance decision by the believer. however. The diographic changes (eg. and increase blood flow. . the management of life-threatening ane- waiver releasing physicians of liability for any con. rang- and kept in anticoagulant-containing bags that ing from transient arrhythmias and electrocar- maintain a constant link to the patient’s body. myopathy appears to increase with a cumulative . erative blood salvage have been accepted by some Witnesses. ST-segment and T-wave blood could be replaced by an acceptable colloid abnormalities) to irreversible cardiomyopathy or crystalloid solution then reinfused as needed and congestive heart failure. This is particu- 1 million Americans. Witnesses abstain from blood and blood products (eg. Lisowska B. Anesthesia in the Patient Receiving Antithrombotic or Liu SS. altering drugs or medications. Loland VJ. placebo-controlled study. and anemia.101:1634. Wu CL: A Thrombolytic Therapy: American Society of Regional comparison of regional versus general anesthesia Anesthesia and Pain Medicine Evidence-Based for ambulatory anesthesia: A meta-analysis of Guidelines. Mariano ER. et al: A preemptive general and regional anesthesia on the incidence multimodal pathway featuring peripheral nerve of post-operative cognitive dysfunction and post- block improves perioperative outcomes after operative delirium: A systematic review with meta- major orthopedic surgery. American Society of Regional randomized controlled trials. features and echocardiography of embolism during cemented hip arthroplasty.27:553. Cheung Y. et al: Continuous interscalene brachial plexus block via an ultrasound- guided posterior approach: A randomized. et al: Minimally prescribed by a physician for severe pain are invasive total knee arthroplasty: A systematic review. et al: Ambulatory dose greater than 550 mg/m2. and complications.33:510. triple- Witnesses generally refrain from any mind. Anesth Analg Anesthesia. masked. Loland VJ. Can J Anaesth. Available at: http://www. prior radiotherapy.29:329. 2010. Dilger JA. Arthroscopy 2009. J Alzheimers Dis 2010. leukopenia. . Di Cesare PE: Hip 2009. Anesthesiology 2008. CHAPTER 38 Anesthesia for Orthopedic Surgery 803 Ilfeld BM. Maldyk P. Le LT. Insertion of an epi- Orthop Clin N Am 2009. Kalonji MK. Meyer RS. Reg Anesth Pain Med analysis.asra. placebo-controlled study. Donohue MC: The association phy. resurfacing arthroplasty: A review of the evidence Mariano ER.com/ 2005. 2010. triple- SUGGESTED READING masked. et al: Upper extremity Ilfeld BM. Gearen PF. Duke KB. outcome. Ilfeld BM.40:479. Clin Rheumatol 2008.22(Suppl 3):67. Richman JM. et al: Regional surgeries. J Ultrasound Med arthroscopy as a cause of glenohumeral chondrolysis. triple- Mild degrees of cardiomyopathy can be detected masked. 2008. arthroplasty. 2009. Rutkowska-Sak L. Gougoulias N. hip arthroplasty: A dual-center. Byer DE. Strodtbeck WM.108:703. Barre J. 2008. et al: A trainee- for surgical technique. Sandhu NS. Enneking FK: Continuous peripheral regional anesthesia: Essentials of our current nerve blocks at home: A review. Hebl JR. Ball ST. or exercise radionuclide angiogra. Mason SE. et al: GUIDELINES Anaesthesiological problems in patients with rheumatoid arthritis undergoing orthopaedic Horlocker TT. Rowlingson JC.109:491. interscalene perineural catheters with a new technique Busfield BT. Ritchie CW: The impact of Hebl JR.100:1822. Romero DM: Pain pump use after shoulder using ultrasound guidance alone. Anesth Analg Amanatullah DF. echo. continuous posterior lumbar plexus nerve blocks after and concurrent cyclophosphamide treatment.111:1552. Noel-Storr A. randomized. et al: Ambulatory Are there any special considerations regarding continuous femoral nerve blocks decrease time postoperative pain management in the to discharge readiness after tricompartment Jehovah’s Witness? total knee arthroplasty: A randomized. The other important toxicity of doxorubicin is between lower extremity continuous peripheral myelosuppression manifesting as thrombocytope. Longo UG.108:1688. 2008. Neal JM.44:112. placebo-controlled trial. Anesth Analg 2010. et al: Clinical anesthetics.php. publications-anticoagulation-3rd-edition-2010. cardiography. Wedel DJ. 3rd ed.41:263. Anesthesiology preoperatively with endomyocardial biopsy. Afra R. dural catheter can provide pain relief with local Lafont ND.34:134. Anesth Analg understanding. Ilfeld BM. nerve blocks and patient falls after knee and hip nia. although opioids Khanna A. with or without opioids. based randomized comparison of stimulating Orthop Clin North Am 2010. accepted by some believers. 1997.25:647. Reg Anesth Pain Med 2005. Gerancher JC. et al: Intrathecal meta-analysis of randomized trials. Schiferer A. Sessler DI. 2000. 1998. et al: A comparison of review. Anesth Analg fracture.17:463. Bent E. Matthews R.102:1240. Griffiths R: General versus arthroscopy. et al: The effects femoral-sciatic nerve blocks after total knee of red-cell scavenging. Nichols R.81:684. of epidural analgesia with combined continuous Schmied H. et al: A comparison arthroplasty.97:1452.804 SECTION III Anesthetic Management Pietak S. Taylor R. J Clin radiological outcomes of hip resurfacing versus total Anesth 2005. . hemodilution. hip arthroplasty: A meta-analysis and systematic Pollock JE. Parker MJ. dose-ranging study after hip and knee Zaric D. Anesth Analg 2003.86:387. Holmes J. controlled. regional anaesthesia for hip fracture surgery: A Rathmell JP.84:450. two regional anesthetic techniques for outpatient knee Urwin SC. Acta Orthop 2010. Christiansen C.97:397. Can J Anaesth 1997. Anesth Analg 2003. et al: The clinical and surgery in the upright position: A case series. and active replacement. Pino CA. Br J Anaesth morphine for postoperative analgesia: A randomized. Mulroy MF.44:198. Cullen DJ: Cerebral ischemia during shoulder Smith TO. Donell ST. Pohl A. et al: Cardiovascular warming on allogenic blood requirements in patients collapse after femoral prosthesis surgery for acute hip undergoing hip or knee arthroplasty. Anesth Analg 2006. Boysen K.
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