Orthopedics and podiatry
A Arthroscopy
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.
a) Complications: Complications from arthroscopic procedures represent a small percentage of the total number of procedures performed.
(1) The full range of potential anesthetic complications associated with patient positioning applies (e.g., inadvertent extubation, eye or corneal injury, and nerve injury from improper patient positioning).
(2) Because of the less invasive nature of arthroscopic procedures, concerns over blood loss are typically minimal. However, sudden sustained hypotension is a cause for immediate investigation.
(3) Perforation of a major blood vessel may occur during trocar insertion and may not be detected until the tourniquet is deflated. Such vascular injury may result from pressure exerted by excessive extravasated irrigation fluid during the procedure.
(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.
(a) Depending on the complexity of the arthroscopic procedure, a large number of irrigation fluid bags may be required.
(b) Small individual inflow/outflow deficits may result in significant fluid absorption by the patient over the course of an extended procedure.
(c) Fluid absorption is of particular concern for shoulder or hip arthroscopic procedures in which fluid absorption is not relatively limited by the use of the pneumatic tourniquet.
(d) Absorption of excessive extravasated fluid may lead to the development of signs and symptoms of congestive heart failure, pulmonary edema, volume overload, or hyponatremia.
(e) If the patient experiences these symptoms, treatment with fluid restriction, supplemental oxygen, and diuresis should be instituted.
(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.
a) History and physical examination: Individualized
(1) Radiographs of the affected extremity
(2) Chest radiography, electrocardiography (ECG), and laboratory tests as indicated
a) Standard monitoring equipment
b) Standard drugs for general or regional anesthesia
e) Circuit extension if table positioned away from anesthesia practitioner
a) Induction: Standard induction with routine medications are used.
(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.
a) Pain is usually minimal to moderate, unless reconstruction was performed.
(1) Intraarticular injections of local anesthetics or opioids are now widely used in an attempt to provide postoperative analgesia.
(2) Inadequate pain control can lead to decreased mobility and an increased incidence of postoperative complications.
b) Swelling or edema: Assess capillary refill in the affected extremity and avoid overhydration intraoperatively.
B Foot and ankle surgery
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.
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
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
2. Preoperative assessment and patient preparation
a) History and physical examination
(1) With this elderly population, assess for coexisting medical diseases.
(2) Carefully assess blood volume, central venous pressure, and orthostatic hypotension because dehydration may mask hemoglobin changes resulting from hematoma formation.
(1) Radiographs: Hip and chest
