Orthopedics and podiatry

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SECTION IX

Orthopedics and podiatry

A Arthroscopy

1. Introduction

    Arthroscopic surgery may be performed for diagnostic or therapeutic indications most often involving the ankle, knee, shoulder, hip, or wrist. Advances in arthroscopy permit many procedures to be performed primarily or adjunctively through the arthroscope. Arthroscopic surgery has replaced some procedures that previously were performed through open techniques. Most of these procedures are done in young, healthy patients. The advantages include minimal incisions, decreased postoperative morbidity, and potentially faster rehabilitation.

2. Preoperative assessment and patient preparation

a) Arthroscopic procedures may be anesthetically managed by almost any of the available anesthesia techniques (general anesthesia, regional anesthesia, combined regional and general anesthesia, local blockade, and sometimes monitored anesthesia care).

b) Patient selection for a given anesthetic technique is crucial with arthroscopic procedures, as with all operative procedures. Critical factors in the selection of the available anesthesia techniques appropriate for arthroscopic procedures are the patient positioning necessary to facilitate the proposed arthroscopic procedure and the overall state of health of the patient.

c) The choice of position is determined by the surgeon’s operating requirements. Reviewing the patient’s chart and, most important, personally interviewing the patient, along with understanding the physiologic changes associated with various positions, will assist the anesthesia provider in offering the best suggestion for anesthesia care for each patient.

d) The factors in the decision are listed in the following box.

Anesthetic Selection in Orthopedics

3. Perioperative management

a) Complications: Complications from arthroscopic procedures represent a small percentage of the total number of procedures performed.

b) Other considerations

(1) To provide optimal visualization of joint structures during arthroscopic procedures, the irrigating fluid used to distend the operative joint is instilled under pressure.

(2) Take note of any deficits of inflow versus outflow of irrigating solution throughout the procedure.

(3) Although the mechanism of occurrence has not been delineated, subcutaneous emphysema, tension pneumothorax, and pneumomediastinum have been reported during shoulder arthroscopy, specifically subacromial decompression.

4. Anesthetic technique

5. Room preparation

6. Perioperative management

a) Induction: Standard induction with routine medications are used.

b) Positioning

(1) Most often, the supine position is used for arthroscopic procedures of both the upper and lower extremities.

(2) Arthroscopy on the knee requires the supine position with the foot of the operating room bed lowered. The nonoperative leg should either have a sequential compression device or some form of antiembolic stocking in place to reduce pooling of blood and reduce the potential for thrombus formation.

(3) Patients undergoing elbow arthroscopy may be placed in the supine, lateral decubitus, or prone position; the position is dictated by operative necessity and surgeon preference. The prone position is more advantageous primarily because of the better limb stability during the procedure.

(4) Shoulder arthroscopy is usually accomplished by either the modified Fowler position (beach chair position) or the lateral decubitus position, based on optimal access to the injury and surgeon preference. Because this procedure does not use a tourniquet, deliberate hypotension may be requested by surgeons. Blood pressure cuff measurements taken on the arm are not representative (underestimate) perfusion pressure in the brain when patients are in a sitting position. Therefore, it is recommended to maintain preoperative mean arterial pressures to avoid hypoxic brain injury.

(5) Hip arthroscopy is also typically accomplished by the lateral decubitus position or the supine position, with the patient on a fracture table. The fracture table is used to provide greater stability while traction is applied using either weights and counterweights (lateral decubitus position) or mechanical traction attached to the leg-holding device of the fracture table (supine position).

c) Tourniquet use: See the discussion of knee arthroscopy later in this section.

d) Emergence: The patient is usually extubated in the operating room unless there was preoperative respiratory compromise.

7. Postoperative implications

B Foot and ankle surgery

1. Introduction

    The feet and ankles are the basis of support on which the remainder of the body rests. Surgical correction of maladies and deformities of the feet and ankles falls under the scope of practice of two specialists: the orthopedic surgeon and the doctor of podiatric medicine, or podiatrist. Both these specialists are highly skilled in foot and ankle surgery to correct the multitude of maladies and deformities that occur with the feet and ankles.

    The most commonly performed procedures on the ankle involve surgical repair of ankle fractures and fusion of the ankle joint. The Achilles tendon is also a frequent focus of surgery, particularly in more physically active persons. The most widely known surgical procedures on the feet are bunionectomy (with or without fusion), correction of hammertoe deformities (with or without fusion), and plantar fasciotomy (either open or endoscopic).

    Open repair of ankle fractures is usually accomplished using plates and screws to hold the bone fragment in proper alignment until the fragments grow back together. Ankle fusion (arthrodesis) is performed for a multitude of medical reasons and may involve two or three bones fused together to provide pain relief and greater joint stability. Incisions are usually made on both the medial and lateral aspects of the ankle joint to allow for optimal surgical access to the involved bones. After the fracture is reduced, a plate is placed across the fracture site(s). Holes are drilled with the plate acting as the template, and screws are placed into these holes. For ankle fusions, the incisions are typically made across the medial and lateral aspects of the joint, and Kirschner wires or screws are used to fuse the appropriate bones in place. The incisions are closed, and some type of inflexible stabilizing device is applied (e.g., cast or plaster splints or ambulatory boot) while the patient is under anesthesia. Pneumatic tourniquets are almost always used to keep blood loss at a minimum and to provide a clear surgical field.

    Bunion deformity usually involves the first or great toe. Incision is made along the anterior surface from about midtoe across the metatarsophalangeal joint. The bony deformity is excised. Depending on the variation of the bunionectomy procedure chosen, excision of the bony deformity may be the totality of the procedure, or the angular deformity may be corrected with a screw or Kirschner wire fusion.

    Hammertoe deformity correction involves incision of the anterior surface of the malformed toe or toes. The incision crosses the joint containing the bony deformity. The surgeon dissects down to the joint and excises the bony deformity. Depending on the severity of the deformity, the interphalangeal joint may be fused by inserting a Kirschner wire.

    Plantar fasciotomy is indicated for severe foot pain during or after ambulating or on arising after sleep, resulting from chronic plantar fasciitis that has not responded to conservative therapy. Open fasciotomy is accomplished through a small incision along the posterior surface of the calcaneus. The plantar fascia is incised to relieve the tension across the plantar arch. Endoscopic plantar fasciotomy is accomplished via two “miniature” incisions, one medial and one lateral, at the beginning of the plantar arch. A small trocar is inserted through these incisions. The sheath of the trocar is slotted to allow visualization of the plantar fascia with the endoscope. The full thickness of the plantar fascia is incised, and the skin incisions are closed.

2. Anesthetic technique

a) Patients scheduled for foot or ankle surgery are excellent candidates for regional anesthesia.

b) Most surgical procedures on the foot or ankle can be accomplished within a 2-hour time frame, often on an outpatient basis.

c) Spinal anesthesia provides sufficient surgical anesthesia to allow completion of most procedures. However, the postanesthesia recovery phase may be unacceptably long and may require the patient to spend a night in the hospital or outpatient facility, which may be unacceptable to the patient.

d) Nerve blocks are especially effective for surgical procedures on the foot or ankle. Posterior tibial nerve block, Mayo blockade, and Bier block are examples of blocks that are effective for foot and ankle procedures.

e) One may provide IV sedation by either continuous infusion or intermittent bolus to provide amnesia and to minimize or eliminate any anxiety the patient may have. The surgeon can inject the surgical site with long-acting local anesthetic (e.g., bupivacaine) to maintain the patient’s comfort immediately and for several hours postoperatively.

C Forearm and hand surgery

1. Introduction

    Surgical procedures on the hand or forearm may be precipitated by violent trauma resulting in complex or dislocated fractures to the bones of the forearm, hand, or fingers, or they may be performed to alleviate numbness of the hand resulting from compression of the nerves of the forearm or wrist, such as carpal tunnel syndrome. Procedures on the fingers and hand are often relatively quick, requiring 1 hour or less to complete. Surgical correction of complex or dislocated fractures of the forearm may require considerable instrumentation and time to complete. For virtually all surgical procedures of the hand and forearm, a pneumatic tourniquet is used.

2. Anesthetic technique

a) Patients scheduled for surgical procedures on the forearm or hand are excellent candidates for regional anesthesia.

b) Axillary block and Bier block provide excellent surgical anesthesia for most surgical procedures of the forearm and hand that are anticipated to require 1 hour or less to accomplish.

c) For procedures precipitated by traumatic injury, such as complex, comminuted fractures or reconstruction of the vascular and nerve structures of the hand or forearm (procedures that may require considerable amounts of time to accomplish), the better anesthetic choice may be general anesthesia.

d) Tourniquet pain becomes an issue with such longer procedures if regional anesthesia is chosen.

e) In addition, for a patient requiring surgery as the result of traumatic injury, the issue of the patient’s nothing by mouth (NPO) status becomes important. Frequently, trauma patients have eaten or ingested liquids close to the time of the traumatic injury. Alcohol may be a precipitating factor in the traumatic injury as well. For these reasons, rapid-sequence induction of general anesthesia may be a more appropriate anesthetic course.

D Hip arthroplasty

1. Introduction

    The replacement of joint surfaces is required primarily for inflammatory or degenerative conditions within the joint, such as those accompanying rheumatoid arthritis or osteoarthritis from degeneration of the synovium or cartilage. As normal joint tissues deteriorate or degenerate, the bone ends are exposed, causing pain and limitation of joint movements. Joint stiffness and muscle atrophy follow, further increasing pain and limiting movement and mobility. Exposed bone surfaces lead to bone growth that may eventually adhere to the opposing bone ends, causing bony ankylosis and loss of joint movement. Therefore, replacement of the deteriorated or degenerated tissues and bones restores movement and relieves pain.

    The hip joint is one of the most frequently replaced joints. Typically, the patient is placed in the lateral decubitus position, which offers greater range of motion and visibility throughout the surgical procedure. This procedure requires a large incision, extending from near the iliac crest across the joint to the midthigh level. Several large muscle groups must be incised and dissected through to gain access to the joint, after which the joint is disarticulated. The femoral head and neck are excised, leaving the femoral canal open. The femur is filled with rich marrow because it is one of the erythrocyte production areas for the body; therefore, it is also richly vascular. The acetabulum is a part of the pelvic girdle, also one of the erythrocyte production areas, and is richly vascular as well. After the femoral head and neck are removed, the femoral canal is reamed to the appropriate diameter to accommodate the prosthetic head and neck. The acetabulum is then reamed in a similar manner to accommodate its own prosthesis. During the reaming for both prosthetic components, bone is shaved from the canal and acetabulum to produce a smoother bony surface to achieve better adherence of the prosthetic device and cement. Also during the reaming process, venous sinuses within these bony structures are opened and often destroyed, and this can result in significant blood loss.

    After the femoral canal has been satisfactorily prepared, the canal is cleaned out using pulse irrigation, which forces irrigation solution deep within the femoral canal under pressure in a high-frequency, pulsatile manner. The canal is further cleaned with a sponge, after which methylmethacrylate (MMA) cement may be instilled into the femoral canal. For some procedures, usually in younger or very physically active patients, MMA is not used to secure the femoral prosthesis, and the prosthesis is referred to as being “press-fit.” After instillation of the MMA cement, the femoral prosthesis is inserted into the canal and is forcibly seated with a mallet. The acetabular component is secured in place with screws and bone grafting. The dislocated joint is reduced, and the soft tissues are returned to normal anatomic position during wound closure.

2. Preoperative assessment and patient preparation

a) History and physical examination

b) Diagnostic tests

c) Preoperative medications and IV therapy

3. Room preparation

4. Anesthetic technique

a) Considerations: Regional blockade, general anesthesia, or a combination of both

b) Technique of choice

c) Regional blockade

d) General anesthesia

e) Induction

(1) General anesthesia

(2) Maintenance

(3) The anesthesia provider must be particularly cognizant of the possible occurrence of hypotension, hypoxia, and potential cardiovascular collapse. These complications are observed most often during insertion of the femoral prosthesis during total hip arthroplasty.

(a) Possible causes of these complications include the MMA cement, fat embolism, air embolism, thromboembolism, and bone marrow embolism.

(b) MMA has been demonstrated to produce significant increases in both pulmonary vascular resistance and pulmonary wedge pressure while decreasing systemic vascular resistance, cardiac output, and arterial pressure.

(c) MMA cement is used to distribute the forces of the femoral and acetabular prosthetic components.

f) Emergence

5. Postoperative implications

a) Obtain laboratory results: Hemoglobin and hematocrit; watch for hidden bleeding.

b) Fat embolism typically appears 12 to 48 hours after a long bone fracture.

E Hip pinning (open reduction and internal fixation)

1. Introduction

    Hip pinning involves the open reduction of a hip fracture that is maintained by the application of plates and screws (internal fixation). Bone grafting may be used to repair any defects. Hip fractures may result from high-impact trauma, but most result from minor trauma in elderly persons. If the fracture is related to high-impact trauma, a coexisting trauma should be thoroughly evaluated.

2. Preoperative assessment and patient preparation

3. Room preparation

a) Monitoring equipment: Standard, arterial line, central line as needed

b) Additional equipment

c) Drugs

4. Perioperative management and anesthetic technique

a) Regional and general anesthesia are both options for elderly patients.

b) Hip pinning may be performed using subarachnoid block or continuous epidural infusion extending to the T8 sensory level. Keep in mind the expected length of the procedure, the patient’s history and physical examination findings, and the patient’s level of cooperation and ability to lie still. Major advantages of regional anesthesia is a decreased incidence of postoperative thromboembolism and another is reduced blood loss. This is thought to be the result of peripheral vasodilation and maintenance of venous blood flow in the lower extremities. Local anesthetics also inhibit platelet aggregation and stabilize endothelial cells. Difficult patient positioning and altered landmarks related to degenerative changes of the spine may increase the technical difficulty of performing a regional block. Postdural puncture headaches are not as prevalent in the elderly population.

c) If a general anesthetic is the best choice for the patient, drugs for induction and maintenance should reflect findings from the patient’s history and physical examination. One advantage of general anesthesia is that the anesthetic can be induced with the patient on the bed or stretcher before moving to the operating table, thus avoiding painful positioning. A disadvantage of general anesthesia is that the elderly patient cannot be positioned for maximal comfort. Consider the use of nondepolarizing muscle relaxants during induction if there are no airway concerns. Continued muscle relaxation is optional and is left to the discretion of the anesthesia provider or the request of the surgeon. The effects of nondepolarizing muscle relaxants that are renally excreted may be slightly prolonged in elderly persons because of reduced drug clearance.

d) Emergence: An epidural catheter may be placed for supplemental use with general anesthesia or for postoperative pain control.

e) Fat embolization: See the discussion of pelvic reconstruction later in this section.

5. Postoperative implications

    

F Knee (total knee replacement) arthroplasty

1. Introduction

    Total knee arthroplasty is the other frequently performed joint replacement procedure. A pneumatic tourniquet is typically used to provide a relatively bloodless surgical field. Nevertheless, blood loss as a result of total knee arthroplasty can be significant. During the procedure, the articulating surfaces of the femur and tibia are excised by precise angular cuts, and the patellar articulating surface is shaved, all to conform the bones to the inner surfaces of the prostheses. Both the femoral and tibial surfaces are covered with MMA cement, and the individual prosthesis components are forcibly seated with a mallet. The high-density polyethylene patellar component is cemented and seated with a viselike clamp. The medial and lateral menisci are replaced with a conforming wedge of high-density polyethylene.

2. Preoperative assessment

    Assessment is routine, including history and physical examination. These patients have been diagnosed with arthritis of the knee.

a) Respiratory: These patients may have rheumatoid arthritis and associated pulmonary conditions. Pulmonary effusions may be present. Rheumatoid arthritis involving the cricoarytenoid joints may exhibit itself by hoarseness. A narrow glottic opening may lead to a difficult intubation. Arthritic involvement of the cervical spine and temporomandibular joint may also complicate airway management.

b) Cardiovascular: Depending on the severity of the arthritis, the patient may have a lowered exercise tolerance. Rheumatoid arthritis is associated with pericardial effusion. Cardiac valve fibrosis and cardiac conduction abnormalities can occur with possible aortic regurgitation. Test with an ECG and, if possible, an echocardiogram and cardiac nuclear imaging.

c) Neurologic: A thorough preoperative neurologic examination may yield evidence of cervical nerve root compression. If indicated, obtain lateral neck radiographs for the determination of stability of the atlanto-occipital joint.

d) Musculoskeletal: Positioning may be difficult because of pain and the decreased mobility of the joints.

e) Hematologic and laboratory: Obtain hemoglobin and hematocrit and other tests related to the history and physical examination.

f) Premedication is individualized based on the patient’s need.

3. Room preparation

4. Anesthetic technique

5. Perioperative management

a) Induction: Standard induction with routine medications. Muscle relaxation is needed for the placement of the prosthesis.

b) Monitor fluid and blood therapy.

c) Requires the supine position with the foot of the operating room bed lowered. The nonoperative leg should either be wrapped with an elastic bandage or have some form of antiembolic stocking in place to reduce pooling of blood and reduce the potential for thrombus formation.

d) Monitor for physiologic changes that are caused by tourniquets.

e) Safety measures for preventing tourniquet complications are listed in the box below. Use of MMA can increase both pulmonary vascular resistance and pulmonary wedge pressure while decreasing systemic vascular resistance, cardiac output, and arterial pressure. MMA causes direct vasodilation, and these effects can last up to 10 minutes.

Physiologic Changes Caused by Limb Tourniquets

f) Emergence: These patients are usually extubated in the operating room unless there was preoperative respiratory compromise.

6. Postoperative implications

    Watch for posterior tibial artery trauma, peroneal nerve palsy (foot drop), hemorrhage from the posterior tibial artery, thromboembolism, and tourniquet nerve injury, if indicated.

G Pelvic reconstruction

1. Introduction

    Pelvic reconstruction is a surgical procedure that involves open reduction of pelvic fractures, which are then maintained by the application of plates and screws. Bone grafting may be used to repair any defects of the pelvis. The surgical time for the procedure is 3 to 6 hours. These fractures may be caused by minor trauma, especially in elderly persons, but most result from high-impact trauma (i.e., motor vehicle trauma). Evaluation of the patient for potential coexisting trauma should include a thorough neurologic, thoracic, and abdominal assessment. The extremities may also be involved.

2. Preoperative assessment

a) History and physical examination: Obtain a verbal history from the patient or family member. Note any preexisting disease processes, social history, current medications, surgical history, and allergies.

(1) Cardiac: Assess for cardiac contusion or aortic tear. Tests include 12-lead ECG, creatine phosphokinase isoenzymes, and chest radiography (wide mediastinal silhouette suggests aortic tear). Transesophageal echocardiography or angiography is indicated if an aortic tear is suspected. Consult with a cardiologist if indicated.

(2) Respiratory: Assess for possible hemothorax, pneumothorax, pulmonary contusion, fat embolism, and aspiration. The patient may require supplemental oxygen or mechanical ventilation to correct hypoxemia. Coexisting trauma to the head or cervical spine may require fiberoptic intubation. Tests include chest radiography and arterial blood gases.

(3) Neurologic: A thorough neurologic evaluation including mental status and peripheral sensory examination. Note any preexisting deficits. Consult with a neurologist if necessary. For tests, computed tomography of the head is indicated before anesthesia for patients who experience a loss of consciousness.

(4) Renal: Renal injury is possible with high-impact trauma. Rule out a urethral tear before placing the Foley catheter. A suprapubic catheter may be necessary. Intraoperative monitoring of urine output is mandatory to assess adequate renal perfusion. Consult a urologist if necessary. Tests include urinalysis, blood urea nitrogen, serum creatinine, hematuria, and myoglobinuria.

(5) Musculoskeletal: Cervical spine clearance may be required before neck manipulation (i.e., laryngoscopy). Consider evaluating thoracic and lumbar radiographs to rule out any deformity or instability before anesthesia. Tests include cervical spine radiography and others as indicated from the history and physical examination.

(6) Hematologic: Large blood loss associated with traumatic injury may occur. The patient’s hematocrit should be restored to greater than 25% before induction of anesthesia. Type and crossmatch for 6 units of packed red blood cells. Consider the use of a cell saver intraoperatively.

(7) Gastrointestinal: Patients should be assessed for abdominal injury associated with trauma. The test used is diagnostic peritoneal lavage.

b) Patient preparation

3. Room preparation

a) Monitoring equipment: Standard, arterial line, central venous pressure, two large peripheral IV catheters

b) Additional equipment

c) Drugs

(1) Continuous infusions: Consider the use of an IV narcotic infusion. If an epidural catheter is placed for postoperative pain control, consider an intraoperative continuous infusion to decrease anesthetic requirements.

(2) IV fluids and blood: Estimated blood loss is greater than 1000 mL. Type and crossmatch the patient for 6 units of packed red blood cells. Blood loss is replaced 1:1 with blood products or colloid solutions or 3:1 if crystalloid solutions are used. Consider the intraoperative use of a cell saver. Maintain urine output at 0.5 to 1 mL/kg/hr. Consider the use of deliberate hypotension to control blood loss in patients without cardiovascular disease or carotid stenosis. Isoflurane, esmolol, sodium nitroprusside, or a combination thereof, titrated to decrease mean arterial pressure by 30% (but not less than 60 mmHg), is commonly used. Any fluid deficits must be replaced before the institution of deliberate hypotension.

(3) Tabletop is standard.

4. Perioperative management and anesthetic technique

a) Induction and maintenance

(1) Rapid-sequence induction must be used for trauma patients to decrease the risk of aspiration.

(2) A standard induction may be used if the procedure is performed electively. Severe hypotension can occur because of hypovolemia.

(3) Because of the painful nature of the injury, induction is best performed on the patient’s bed or stretcher before moving to the operating table.

(4) Drugs for induction and maintenance should reflect the patient’s history and physical examination and should account for any significant medical history, current physiologic states, and drug allergies.

(5) Consider the use of a nondepolarizing muscle relaxant during induction if there are no airway concerns.

(6) Anesthetic gases should be warmed and humidified. Continued muscle relaxation is optional and is left to the discretion of the anesthesia provider or the request of the surgeon.

b) Emergence

c) Fat embolization

5. Postoperative implications

H Upper extremity arthroplasty

1. Introduction

    Arthroplasty in the upper extremity makes up a low percentage of the number of joint arthroplasties performed each year. Of the two more commonly replaced upper extremity joints (the shoulder and the elbow), shoulder arthroplasty accounts for approximately 5% of the total number of joint replacements performed each year. The primary goal of shoulder arthroplasty is to relieve pain, with the secondary goal being improvement in overall joint functioning. Indications for shoulder arthroplasty include glenohumeral joint destruction as a result of osteoarthritis, complex proximal humerus fractures, rheumatoid arthritis, avascular necrosis of the humeral head, and malunion or nonunion of the proximal humerus.

    Shoulder arthroplasty is performed with the patient in either the lateral decubitus or modified Fowler (beach chair) position. Because a pneumatic tourniquet cannot be used, shoulder arthroplasty tends to result in significant intraoperative blood loss.

    Elbow arthroplasty is performed less frequently than shoulder arthroplasty. The goals for elbow arthroplasty are much the same as for shoulder arthroplasty: pain relief and improvement in joint function. The indications for elbow arthroplasty include rheumatoid arthritis, traumatic arthritis, and ankylosis of the joint.

2. Preoperative assessment

a) Respiratory

b) Cardiovascular: Patients with rheumatoid arthritis may have chronic pericardial tamponade, valvular disease, and cardiac conduction defects. If indicated, a consult with cardiologist may be warranted.

c) Neurologic

d) Musculoskeletal: With the possibility of limited neck and jaw mobility, special intubation may be indicated. Special attention must be paid to positioning in patients with bony deformities or contractures to prevent pressure ulcers and neuropathies.

e) Hematologic: Almost all nontrauma patients will be receiving some type of nonsteroidal anti-inflammatory drug, which should be stopped approximately 5 days before the procedure.

f) Endocrine: Patients with rheumatoid arthritis will most likely be receiving some type of corticosteroid; therefore, supplemental steroids should be given to treat adrenal suppression (e.g. IV hydrocortisone 100 mg) in patients on chronic corticosteroid therapy.

g) Laboratory tests: Hemoglobin and hematocrit are obtained from healthy patients; other tests are as indicated from the history and physical examination.

h) Premedication: If a peripheral nerve block is performed, moderate to heavy premedication is indicated.

3. Room preparation

4. Anesthetic technique: Shoulder

a) Patients undergoing total shoulder arthroplasty can be managed by general anesthesia, interscalene block, or supraclavicular block.

b) If general anesthesia is chosen, caution is advised to observe for the ongoing potential for inadvertent extubation as a result of the surgical manipulations necessary while in close proximity to the patient’s head and neck. The patient’s neck may be subjected to excessive stretch during the surgical manipulations, and if the patient’s head becomes dislodged from the supportive device used, there is the potential for cervical spine injury.

c) For the patient undergoing shoulder arthroscopy, pulmonary function will more closely resemble “normal” function as a result of being in the modified Fowler position. This position puts the patients at increased risk for a venous air embolism.

d) Recognize the risk of fat or bone marrow embolism and thromboembolism incumbent with the required reaming of the shaft of one of the body’s long bones. The potential cardiovascular effects of MMA cement must also be considered if the humeral component is cemented in place.

e) Blood loss during shoulder arthroplasty can be significant, just as it can with hip arthroplasty. Minimize blood loss and transfusion (e.g., autologous donation). Deliberate hypotension can be used if the patient is positioned supine and the patient’s cardiovascular and neurologic status are not compromised.

5. Anesthetic technique: Elbow

a) Elbow arthroplasty can be performed in any of three positions: supine, lateral decubitus, or prone.

b) The deciding factors on which position will be used for this procedure are based on surgeon preference and the health of the patient.

c) Elbow arthroplasty can be managed by general anesthesia or supraclavicular, infraclavicular, interscalene, or axillary block.

d) With the patient under general anesthesia, be mindful of the potential complications and physiologic changes associated with each position.

e) During elbow arthroplasty, a pneumatic tourniquet may be used to minimize blood loss and to provide a clear surgical field. Tourniquet: For the upper extremity, the tourniquet is set 50 to 100 mmHg greater than the patient’s systolic blood pressure.

f) Be prepared to treat the patient’s tourniquet pain whenever regional anesthesia is used.

g) Be aware of the increased risk of thromboembolism development when the pneumatic tourniquet is used, particularly in patients with a history of DVT.

6. Perioperative management

7. Postoperative implications

    Consider a patient-controlled analgesia pump or a regional block technique for postoperative pain.

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