Anesthesiologist's Manual of Surgical Procedures, 4th ed.

Orthopedic Surgery

Chapter 10.5

Knee Surgery

James I. Huddleston MD

Surgeon

John J. Csongradi MD

Surgeon

Stuart B. Goodman MD, PhD, FRCSC, FACS

Surgeon

Frederick G. Mihm MD

Anesthesiologist

Christoph Egger Halbeis MD, MBA

Anesthesiologist

P.1014

Arthroplasty of the Knee

Surgical Considerations

Description: In this procedure, an arthrotomy of the knee joint is performed, and metallic and plastic components are used for replacement of the knee joint surfaces (total knee replacement). The femur, patella, and tibia are exposed; cartilage and minimal bone are excised with a saw. The new components may be cemented or uncemented. Alternatively, arthroplasty may be performed on only one compartment of the knee (i.e., medial/lateral unicompartmental knee replacement). In revision procedures, one or more components of the old joint are removed and new components are placed. In resection or excision arthroplasty of the knee, (usually for infection of the prosthesis), the components are removed, but not replaced.

Usual preop diagnosis: Arthritis of knee; arthrosis of knee; loose (or malpositioned) knee prosthesis; infected knee

Summary of Procedures

 

Knee Replacement

Revision

Resection/Excision

Position

Supine

Incision

Anterior or anteromedial over patella

Special instrumentation

Appropriate prostheses and instrumentation

Special instruments for excising cement

Unique considerations

± Tourniquet; ± SCD

Antibiotics

Cefazolin 1 g iv q 6–8 h × 24 h (vancomycin or clindamycin for 24 h if penicillin allergic)

Surgical time

2 h

3–4 h or more

3 h

Closing considerations

In infected or complex revision cases (rare), a local or free flap is required.

EBL

300–500 mL

500–1,000 mL

Postop care

Bulky dressing or splint; continuous passive motion (CPM) may begin in the PACU or ward

Splint/cast

Mortality

Rare

Morbidity

DVT, without prophylaxis: 50–75%

 

DVT, with prophylaxis (e.g., low-molecular-weight heparin, coumadin, SCD, antiembolism stockings): 2–3%

 

Postop subluxation/dislocation of patella: 20%

> 30%

 

Superficial wound necrosis: 10–15%

> 10–15%

≥ 10–15%

 

Wound infection:
  Primary rheumatoid or psoriatic
  arthritis, diabetes: 5–10%

> 5–10%

Rare

 

Primary osteoarthritis (OA): 1%

 

 

 

PE: 1–7%

 

Postop subluxation/dislocation of knee joint: 1–6%

≥ 1–6%

 

Late aseptic loosening requiring revision after ~10 yr: 5%

 

Peroneal nerve injury: 1–5%

> 1–5% (more common in difficult revisions)

1–5%

 

Urinary retention requiring catheterization: Common

 

Hematoma requiring reoperation: Rare

 

Hypotension

 

Knee stiffness

 

Intraoperative fracture: Rare

 

Wound dehiscence: Rare

 

Fat embolism: Rare

 

Vascular injury to popliteal vessels: Rare

Pain score

7

8

9

P.1015

Patient Population Characteristics

Age range

Generally, > 60 yr. Arthritis of the knee (e.g., rheumatoid arthritis or juvenile rheumatoid arthritis); hemophilia, ≥ 18 yr

Male:Female

1:1

Incidence

Common (~400,000/yr in the United States)

Etiology

Arthrosis of the knee (degenerative joint disease [DJD] or OA); seropositive or seronegative arthritis; traumatic arthritis; hemophiliac arthropathy of the knee

Associated conditions

Dependent on primary condition (e.g. osteoarthritis)

Anesthetic Considerations

See Anesthetic Considerations for Knee Procedures (p. 1026).

Suggested Readings

  1. Blaster RB, Matthews LS: Complications of prosthetic knee arthroplasty. In: Complications in Orthopaedic Surgery,3rd edition. Epps CH Jr, ed. JB Lippincott, Philadelphia: 1994, 1057–86.
  2. Burke DW, O'Flynn H: Primary total knee arthroplasty. In Chapman's Orthopaedic Surgery,3rd edition. Chapman MW, ed. Lippincott Williams & Wilkins, Philadelphia: 2001, 2869–96.
  3. Guyton JL: Arthroplasty of the ankle and knee. In: Campbell's Operative Orthopaedics,9th edition. Crenshaw AH, ed. Mosby-Year Book, St. Louis: 1998, Vol 1, 232–94.
  4. Insall JN: Total knee replacement. In: Surgery of the Knee.Insall JN, ed. Churchill Livingstone, New York: 1984, 587–695.
  5. Kuper M, Rosenstein A: Infection control in total knee and total hip arthroplasties. Am J Orthop2008; 37(1):E2–5.
  6. NIH Consensus Statement on total knee replacement. NIH Consens State Sci Statements. 2003; 20(1):1–34.
  7. Vince KG: Revision knee arthroplasty and arthrodesis of the knee. In Chapman's Orthopaedic Surgery,3rd edition. Chapman MW, ed. Lippincott Williams & Wilkins, Philadelphia: 2001, 2897–2952.

Arthrodesis of the knee

Surgical Considerations

Description: In this procedure, the femur is fused to the tibia, obliterating the knee joint. Through a midline incision and anterior or median parapatellar arthrotomy, the cartilage surface and a small amount of bone are excised. The cut ends are opposed and aligned in 0–20° of flexion and 5–10% of valgus. The bones are stabilized with plates, screws, an intramedullary rod, or an external fixator.

Usual preop diagnosis: Arthritis or other arthrosis of the knee; previous septic arthritis of the knee; failed or infected knee arthroplasty

P.1016

Summary of Procedures

Position

Usually supine

Incision

Anterior midline over knee

Special instrumentation

External fixator; internal fixation with plates and screws or intramedullary nail

Unique considerations

Intraop radiographs or I.I.; tourniquet

Antibiotics

Cefazolin 1 g iv q 6–8 h × 24 h (vancomycin or clindamycin for 24 h if penicillin allergic)

Surgical time

3 h (+ 1 h, if necessary, to excise total knee arthroplasty)

Closing considerations

Cast or splint while anesthetized

EBL

< 100 mL, if tourniquet and local fixation used.
500–1000 mL, if no tourniquet used, or if intramedullary procedures are used.

Mortality

Rare, but depends primarily on age and medical condition of patient.

Morbidity

Thromboembolism ≥ incidence following total knee replacement:
DVT (without prophylaxis): 50–75%
DVT (if prophylaxis used): 10–20%
PE (if no prophylaxis; reduced if anticoagulation or SCDs used): 1–7%
Failure of fusion (nonunion), malunion: 10%
  After failed knee replacement: 19–44%
  With Charcot joint: as high as 50%
  Pin tract infection: ≥ 1–10%
Wound infection: 5%
Deep infection and osteomyelitis
Urinary retention requiring catheterization, UTI: Common
Breakage or failure of internal or external fixation: Rare
Fat embolism: Rare
GI bleed, MI: Rare
Hematoma: Rare
Hypotension: Rare
Intraop femoral or tibial fracture: Rare
Neurological injury, usually popliteal nerve or peroneal nerve: Rare
Superficial wound necrosis and wound dehiscence: Rare
Vascular injury to popliteal vessels: Rare
Amputation: Extremely rare (usually 2° acute arterial occlusion or uncontrollable local sepsis)

Pain score

9

Patient Population Characteristics

Age range

Any age

Male:Female

1:1

Incidence

Rare

Etiology

Failed or infected total knee replacement (probably most common etiology); trauma to knee—unreconstructable, intraarticular fractures; total unstable knee or failed ligament repairs with severe DJD in a young patient

Anesthetic Considerations

See Anesthetic Considerations for Knee Procedures (p. 1026).

P.1017

Suggested Readings

  1. Blaster RB, Matthews LS: Complications of prosthetic knee arthroplasty. In: Complications in OrthopaedicSurgery, 3rd edition. Epps CH Jr, ed. JB Lippincott, Philadelphia: 1994, 1057–86.
  2. Carnesale PG, Stewart MJ: Complications of arthrodesis surgery. In: Complications in Orthopaedic Surgery,3rd edition. Epps CH Jr, ed. JB Lippincott, Philadelphia: 1994, 1279–1308.
  3. Christian CA, Donley BG: Arthrodesis of the ankle, knee, hip. In: Campbell's Operative Orthopaedics,9th edition. Canale ST, ed. Mosby-Year Book, St. Louis: 1998, Vol 1, 145–88.
  4. Mize R, Johnson EE, Hohl M: Complications of fractures and dislocations of the knee. In: Complications in Orthopaedic Surgery,3rd edition. Epps CH Jr, ed. JB Lippincott, Philadelphia: 1994, 525–56.
  5. Vince KG: Revision knee arthroplasty and arthrodesis of the knee. In: Chapman's Orthopaedic Surgery,3rd edition. Chapman MW, ed. Lippincott Williams & Wilkins, Philadelphia: 2001, 2897–2952.

Open Reduction and Internal Fixation (ORIF) of Patellar Fractures

Surgical Considerations

Description: In ORIF of patellar fractures, a short incision over the patella is used to perform a reduction by direct visualization of the fracture fragments of the patella. Since this is generally an intraarticular fracture, the fragments should be reduced precisely. The torn quadriceps retinaculum is also repaired. Part or all of the patella may be excised; pins, wires, and/or screws are normally used to fix the patellar fragments together internally. Thereafter, the knee is casted, or early motion of the knee is started.

Usual preop diagnosis: Fracture of patella; severe degenerative arthritis of patellofemoral joint

Summary of Procedures

Position

Supine

Incision

Anterior over patella

Special instrumentation

Wire, pins, screws as necessary

Unique considerations

Intraop radiographs may be obtained; tourniquet

Antibiotics

Cefazolin 1 g iv q 6–8 h × 24 h (vancomycin or clindamycin for 24 h if penicillin allergic)

Surgical time

1.5–2 h

Closing considerations

Splint or cast usually applied.

EBL

< 100 mL

Mortality

< 1%

Morbidity

Late degenerative arthritis of patellofemoral joint: ~50–60%
DVT: ~5%
Wound infection, septic arthritis, osteomyelitis: ~5%
Delayed union, nonunion, malunion: ~2–5%
Knee stiffness: Common
Weakness: Common
Avascular necrosis: Rare
Complex regional pain syndrome: Rare
Following patellectomy—quadriceps strength: ~75% of normal

Pain score

7

P.1018

Patient Population Characteristics

Age range

Any age; frequently seen in young, active, healthy adults.

Male:Female

1:1

Incidence

~1% of all skeletal injuries

Etiology

Trauma: falls (60%); motorcycle and motor vehicle accidents (25–35%); industrial injury (6%); degenerative arthritis of patellofemoral joint (rare)

Anesthetic Considerations

See Anesthetic Considerations for Knee Procedures (p. 1026).

Suggested Readings

  1. Callaghan JJ, O'rourke MR, Saleh KJ. Why knees fail: lessons learned. J Arthroplasty2004; 19(4 Suppl 1):31–4.
  2. Mize R, Johnson EE, Hoh1 M: Complications of fractures and dislocations of the knee. In: Complications in Orthopaedic Surgery,3rd edition. Epps CH Jr, ed. JB Lippincott, Philadelphia: 1994, 525–56.
  3. Whittle AP: Fractures of lower extremity. In: Campbell's Operative Orthopaedics,Vol 3, 9th edition. Canale ST, ed. Mosby-Year Book, St. Louis: 1998, 2042–2180.
  4. Whittle AP: Malunited fractures. In: Campbell's Operative Orthopaedics,Vol 3, 9th edition. Canale ST, ed. Mosby-Year Book, St. Louis: 1998, 2537–78.
  5. Wiss DA, Watson JT, Johnson EE: Fractures of the knee. In: Rockwood and Green's Fractures in Adults,5th edition. Rockwood CA Jr, Green DP, Bucholz RW, Heckman JD, eds. Lippincott-Raven, Philadelphia: 1996, 1919–71.

Repair or Reconstruction of Knee Ligaments

Surgical Considerations

Description: Collateral ligaments usually are repaired by direct suture or by stapling the torn ligaments to bone. Cruciate tears are generally repaired only if bone is avulsed at one end of the ligament, again with direct suture, staples, or screws. For collateral ligament repair, a longitudinal incision is made directly over the ligament medially or laterally. The ligament is exposed by deep dissection and elevation of skin flaps. The torn ligament is repaired by direct suture or by fixing it to bone with a screw or staple. Following closure, the knee is immobilized with a long leg splint or cast. Cruciate ligaments are repaired in similar fashion, except for the approaches: medial parapatellar (with anterior arthrotomy) for the anterior cruciate ligament (ACL) and posteromedial (with posterior arthrotomy) for the posterior cruciate ligament (PCL). Cruciate ligament reconstruction is performed for instability 2° intrasubstance tears of these ligaments. Homografts, such as a portion of the patellar tendon or semitendinosus tendon, normally are used, but allografts or synthetics also are available. (The ligaments of the knee are illustrated in Figs 10.5-1 and 10.5-2.)

Usual preop diagnosis: Trauma

Summary of Procedures

 

Repair or Collateral Reconstruction

Repair or Cruciate Reconstruction

Position

Supine

Incision

Over collateral ligament

Anterior and lateral ACL or medial PCL

Special instrumentation

Staples

Drill guides, staples, screws

Unique considerations

Often arthroscopically assisted; tourniquet

Antibiotics

Cefazolin 1 g iv (vancomycin or clindamycin if penicillin allergic)

Surgical time

2 h

Closing considerations

Splint or cast while anesthetized

EBL

100 mL

Postop care

PACU → room or home

Mortality

Minimal

Morbidity

Infection: < 1%

 

Thrombophlebitis: < 5%

Pain score

4

7

P.1019

Patient Population Characteristics

Age range

Young adult

Male:Female

2:1

Incidence

Common

Etiology

Trauma: 100%

 

Figure 10.5-1. The cruciate ligaments (posterior view). (Reused with permission from Clemente CD. Clemente's Dissector, 2nd edition. Baltimore: Lippincott Williams & Wilkins, 2007: 270.)

     

P.1020

 

Figure 10.5-2. The knee joint opened anteriorly. (Reused with permission from Clemente CD. Clemente's Dissector, 2nd edition. Baltimore: Lippincott Williams & Wilkins, 2007: 269.)

Anesthetic Considerations

See Anesthetic Considerations for Knee Procedures (p. 1026).

Suggested Readings

  1. Canale ST, ed: Campbell's Operative Orthopaedics,10th edition. Mosby, St. Louis: 2003.
  2. Marder RA, Ertl JP: Dislocations and multiple ligamatous injuries of the knee. In Chapman's Orthopaedic Surgery,3rd edition. Chapman MW, ed. Lippincott Williams & Wilkins, Philadelphia: 2001, 2417–34.
  3. McCulloch PC, Lattermann C, Boland AL, et al: An illustrated history of anterior cruciate ligament surgery. J Knee Surg2007; 20(2):95–104.

Patellar Realignment

Surgical Considerations

Description: The goal of this procedure is prevention of chronic subluxation or dislocation of the patella. Soft tissue components of the surgery include incision (release) of the lateral patellar retinaculum and reefing or tightening of the medial retinaculum (Fig. 10.5-3). In cases of severe malalignment of the extensor mechanism, the insertion of the patellar tendon may be moved to a new, more medial location (tibial tubercle transfer). In this procedure, the tibial tubercle generally is detached with a saw or osteotomes, leaving a bone pedicle attached distally. The tubercle is then rotated medially on the pedicle and fixed in its new position with a screw. Many surgeons routinely perform an anterior compartment fasciotomy to prevent postop compartment syndrome.

P.1021

 

Figure 10.5-3. Outer layer of anteromedial aspect of the knee joint. Shows anatomy of the patellar retinaculum. (Reproduced with permission from Hoppenfeld S, deBoer P:Surgical Exposures in Orthopaedics: The Anatomic Approach. Lippincott Williams & Wilkins: 1994.)

Usual preop diagnosis: Chronic patellar subluxation or dislocation

Summary of Procedures

 

Patellar Realignment

Tibial Tubercle Transfer

Position

Supine

Incision

Anteromedial or anterolateral to knee

Special instrumentation

None

Screws or staples

Unique considerations

Tourniquet

Antibiotics

Cefazolin 1 g iv (vancomycin or clindamycin if penicillin allergic)

Surgical time

1 h

1.5 h

Closing considerations

None

Splint or cast while anesthetized

EBL

50 mL

100 mL

Postop care

PACU → room or home

Mortality

Minimal

Morbidity

Hemarthrosis: 100%

5%

 

Redislocation: 20%

25%

 

Thrombophlebitis: 10–20%

 

Compartment syndrome: < 1%

 

Infection: < 1%

Pain score

6

7

Patient Population Characteristics

Age range

Usually young adult

Male:Female

1:2

Etiology

Trauma (70%); congenital (30%)

Associated conditions

Patellofemoral dysphasia (60–70%)

P.1022

Anesthetic Considerations

See Anesthetic Considerations for Knee Procedures (p. 1026).

Suggested Readings

  1. Epps CH Jr, ed: Complications in Orthopaedic Surgery,3rd edition. JB Lippincott, Philadelphia: 1994.
  2. Griffin LY, Duralde XA: Adolescent sports injuries. In: Chapman's Orthopaedic Surgery,3rd edition. Chapman MW, ed. Lippincott Williams & Wilkins, Philadelphia: 2001, 2493–2536.

Arthroscopy of the Knee

Surgical Considerations

Description: Knee arthroscopy is used to diagnose and treat intraarticular problems, most commonly torn meniscus, but the procedure is also used for ligament injuries (Fig 10.5-1,10.5-2), osteochondral fractures, loose bodies, arthritis, and infections. In knee arthroscopy, multiple portals or entry points for the arthroscope and instruments generally are used. The most common portals are anteromedial and anterolateral adjacent to the patellar ligament. Other portals may be suprapatellar, parapatellar, and posterior. Portals are made by making a stab wound with a knife and then entering the joint with a combination of sharp and blunt trochars. A diagnostic inspection from one of the anterior portals is normally performed at the outset. A second portal is used with a nerve hook to manipulate intraarticular tissues. If resection or repair is performed, the appropriate instruments are inserted through one of the portals. Meniscus repair and cruciate reconstruction may require separate longitudinal incisions, which are usually posteromedial or posterolateral, for placement of sutures and/or drill holes.

P.1023

Meniscectomy and/or debridement often are performed in conjunction with arthroscopy. Cruciate ligament reconstruction usually is performed with arthroscopic assistance. At the end of the procedure, the knee joint is copiously irrigated with NS or LR solution through one of the portals. Portals are closed with a single suture and Steri-Strips®; compression bandages are applied; and often a knee immobilizer is used.

Usual preop diagnosis: Torn meniscus; cruciate ligament tear; arthritis

Summary of Procedures

 

Arthroscopy

Meniscectomy/Debridement

Cruciate Reconstruction

Position

Supine

Incision

3–4.5 cm portals

⇐ + anterior midline and lateral

Special instrumentation

Arthroscopic video system; small biters and graspers

⇐ + shaver

⇐ + drill guides and drills; fixation screws

Unique considerations

Thigh holder; foot of table 90°; ± tourniquet

Antibiotics

Cefazolin 1 g iv (vancomycin or clindamycin if penicillin allergic)

Surgical time

0.5 h

1–2 h

2–3 h

Closing considerations

No splint; local anesthetic injected

EBL

Minimal

50 mL

Postop care

PACU → home

⇐ or overnight

Mortality

< 0.1%

Morbidity

Hemarthrosis: 5–20%

5%

 

Thrombophlebitis: < 2%

 

Infection: 0.1%

 

Stiffness: < 0.1%

< 4%

Pain score

3

4

6

Patient Population Characteristics

Age range

10–70 yr (usually 20–40 yr)

Male:Female

2:1

Incidence

The most common arthroscopic procedure (85% of total)

Etiology

Trauma (~85%); arthritis (~10%); infection (~5%)

Associated conditions

Usually healthy; systemic arthritis (< 5%)

Anesthetic Considerations

See Anesthetic Considerations for Knee Procedures (p. 1026).

Suggested Readings

  1. Coward DB: Principles of arthroscopy of the knee. In Chapman's Orthopaedic Surgery, 3rd edition. Chapman MW, ed. Lippincott Williams & Wilkins, Philadelphia: 2001, 2269–98.

P.1024

  1. McGinty JB, ed: Operative Arthroscopy. 3rd edition. Lippincott Williams & Wilkins, Philadelphia: 2002.
  2. Silvis ML, Clinch CR, Tillett JS, et al: Clinical inquiries. What is the best way to evaluate an acute traumatic knee injury? J Fam Pract2008; 57(2):116–8.

Knee Arthrotomy

Surgical Considerations

Description: Arthrotomy of the knee is the opening of the joint for drainage, excision of intraarticular tissue (synovium, meniscus, loose bodies), ligament repair/reconstruction, or fracture fixation. The knee generally is opened with a parapatellar incision, either medial or lateral, and the joint capsule is incised just adjacent to the patella. After the intra-articular pathology is addressed, a tight capsular closure is performed, followed by subcutaneous tissue and skin closure.

Variant procedure or approaches: Arthrotomy with debridement may be used for infection or arthropathy which produces debris. In both cases, synovectomy may be necessary.

Usual preop diagnosis: Infection; trauma (fracture, sprain, torn meniscus); arthritis

Summary of Procedures

 

Arthrotomy

Arthrotomy with Debridement

Arthrotomy with Synovectomy

Position

Supine

Incision

Medial or lateral parapatellar

Special instrumentation

Tourniquet

Antibiotics

Cefazolin 1 g iv (vancomycin or clindamycin if penicillin allergic)

Surgical time

1 h

2 h

2 h

Closing considerations

Compressive dressing; may be splinted; suction drain

EBL

100 mL

Postop care

PACU → room

Mortality

Minimal

Morbidity

Hemarthrosis: 100%

 

Degenerative arthritis: 5–20%

 

Stiffness: 5%

 

Thrombophlebitis: 5%

 

Infection: 1 %

10%

20%

Pain score

7

7

8

Patient Population Characteristics

Age range

Infant–elderly (usually young adult)

Male:Female

1:1

Incidence

Common

Etiology

Infection; trauma; arthritis

Associated conditions

Inflammatory arthritis (20%)

P.1025

Anesthetic Considerations

See Anesthetic Considerations for Knee Procedures (p. 1026).

Suggested Reading

  1. Epps CH Jr, ed: Complications in Orthopaedic Surgery, 3rd edition. JB Lippincott, Philadelphia: 1994.

Repair of Tendons—knee and leg

Surgical Considerations

Description: Acute ruptures of tendons in the lower limb are repaired by direct suture and sometimes reinforced with part of another tendon. At the knee, patellar tendon ruptures are most common; at the ankle, Achilles tendon ruptures are most common. A longitudinal incision generally is made directly over the tendon. The tendon sheath is opened and tendon ends reapproximated with a nonabsorbable tendon stitch. If necessary, the repair may be augmented by synthetic tape or fascia, or protected with a wire that takes tension off the repair. The tendon sheath is closed separately from the skin incision; and a cast or splint is applied. Achilles tendon repair and posterior tibial tendon repair require different positioning. For an Achilles tendon repair, the patient is placed prone, and a longitudinal incision is made just medial to the tendon, spanning the rupture. The tendon sheath is incised and carefully protected. Torn ends of the tendon are approximated with multiple tendon stitches and may be protected with a fascial flap developed from the gastrocnemius fascia. The tendon sheath is closed carefully, followed by skin wound closure. A splint or cast is applied with the foot in equinus (plantar flexion).

Usual preop diagnosis: Tendon rupture

Summary of Procedures

 

Posterior Tendon Repair

Achilles Tendon Repair

Position

Supine

Prone

Incision

Over tendon

Special instrumentation

Wire or synthetic tape for augmentation

Unique considerations

Tourniquet

Antibiotics

Cefazolin 1 g iv (vancomycin or clindamycin if penicillin allergic)

Surgical time

1 h

Closing considerations

Splint or cast while anesthetized

EBL

Minimal

Postop care

PACU → room or home

Mortality

Minimal

Morbidity

Weakness: ~10%

 

Wound slough: 5%

 

Adhesions: < 1%

 

Infection: < 1%

 

Rerupture: 5–10%

 

Pain score

3

3

P.1026

Patient Population Characteristics

Age range

Any age

Male:Female

1:1

Incidence

Uncommon

Etiology

Trauma (90%); chronic tendinitis (10%)

Associated conditions

Obesity; diabetes mellitus (DM); inflammatory arthritis

P.1027

Anesthetic Considerations for Knee Procedures

(Procedures covered: arthroplasty; arthrodesis; ORIF of patellar fractures; repair/reconstruction of ligaments; patellar realignment; arthroscopy; arthrotomy; tendon repair—knee and leg)

Preoperative

Trauma and osteoarthritis (OA) are the most common indications for these procedures. Trauma patients (e.g., those with sports injuries) are often young and healthy, whereas arthritic patients are often elderly, and anesthetic management must be tailored to any concurrent disease. Patients with rheumatoid and other inflammatory arthritides form another group of candidates for these procedures; the special anesthetic considerations for these patients are described in Anesthetic Considerations for Hip Procedures, p. 997. A final group of patients undergoing these procedures are hemophiliacs, who develop arthritis from recurrent bleeding into their joints. The hematologic management of these patients is discussed below.

Respiratory

These patients often have rheumatoid arthritis and associated pulmonary conditions. For example, pulmonary effusions are common. Limited respiratory reserve warrants further evaluation. Pulmonary fibrosis (rare) often manifests as a cough and dyspnea. Rheumatoid arthritis involving the cricoarytenoid joints may manifest as hoarseness, glottic narrowing, and difficult intubation. Arthritic involvement of the TMJ and cervical spine may further complicate airway management.
Tests: As indicated from H&P.

Cardiovascular

The severity of the arthritis often limits exercise and makes assessment of cardiovascular status difficult. Dobutamine stress ECHO, and dipyridamole thallium imaging may be necessary for an adequate cardiac evaluation. Rheumatoid arthritis is associated with pericardial effusion, cardiac valve fibrosis, cardiac conduction abnormalities and aortic regurgitation (AR).
Tests: ECG and others as indicated from H&P.

Neurological

In arthritic patients, a thorough preop neurological exam often yields evidence of cervical nerve root compression. After the stability of the neck has been established, the full range of neck motion should be evaluated for evidence of nerve compression or cerebral ischemia (suggesting vertebral artery compression). Consider preop lateral neck films to determine stability of atlantooccipital joint and evidence of vertebral spurs that may interfere with intubation.
Tests: As indicated from H&P.

Musculoskeletal

Pain and ↓ joint mobility may make positioning and regional anesthesia difficult in this patient population.

Hematologic

Hemophiliacs require restoration of clotting factors preop. Administer 1 U of factor concentrate/kg body weight for each 2% increase necessary to achieve clotting factor activity of 40% normal. FFP contains l U/mL and cryoprecipitate 20 U/mL. Hemophilia B (Factor IX deficiency), but not hemophilia A (Factor VIII deficiency), can be treated with prothrombin complex concentrate; however, these products can activate clotting factors and → DIC. Approximately 10% of hemophiliacs develop antibodies to exogenous clotting factors, and the care of these patients should be guided by a hematologist.
Tests: Hct; other tests as indicated from H&P.

Laboratory

Other tests as indicated from H&P.

Premedication

Standard premedication (see p. B-1). Preop patellar pain is treated effectively with a femoral nerve block at the inguinal ligament, using 10 mL of lidocaine 1.5% with epinephrine 1:200,000.

Intraoperative

Anesthetic technique: For many of these patients, regional anesthesia may be the preferred technique, offering the advantages of ↓ blood loss, ↓ DVT, minimal respiratory impairment, and effective postop analgesia. Patients with rheumatoid arthritis rarely have involvement of the lumbar spine. Because rheumatoid arthritis frequently affects the C-spine, however, these patients may have limited range of neck motion, an unstable atlantooccipital joint, and cricoarytenoid and TMJ arthritis. Careful airway evaluation, therefore, is important to determine the appropriateness of special intubation techniques (e.g., fiber optic).

Regional anesthesia: A continuous peripheral nerve block (CPNB) provides similar effect on postop length of hospital stay and rehabilitation compared to an epidural pain management but has a lower incidence of side effects (urinary retention, hypotension, and dysesthesia). A combined femoral and sciatic nerve block provides superior pain control in the first 36 postoperative hours over a single, femoral nerve block. In addition to the nerve block, either a GA or a SAB is needed for the intraoperative phase since a CPNB does not reliably provide surgical anesthesia. Both nerves can be localized conventionally using a nerve stimulator or with ultrasound-guidance. A typical initial local anesthesia dose for each nerve is 20 mL of 0.5% bupivacaine or 0.75% ropivacaine.

An epidural block provides both intraop surgical anesthesia and postop pain control but it is contraindicated in patients receiving Coumadin postop. If the patient prefers not to receive a peripheral nerve or an epidural block, a subarachnoid block provides a useful alternative regional anesthesia technique, depending on the patient population (e.g., younger patients may be at ↑ risk of spinal headache following SAB). Anesthesia extending from S2 to T12 (T8, if tourniquet is used) is adequate for knee surgery. Full motor blockade is essential for fixation of the patella, or placement of the joint prosthesis and assessment of the passive ROM of the prosthesis. Typical drugs and doses include: subarachnoid—12.5–15 mg of 0.75% bupivacaine with morphine 0.2 mg; epidural—15–20 mL 2% lidocaine with epinephrine 1:200,000 in divided doses.

General anesthesia:

Induction

 

Standard induction (see p. B-2) is appropriate for patients with normal airways.

Maintenance

 

Standard maintenance (see p. B-2). Neuromuscular relaxation facilitates the placement of the prosthesis. Hemophiliacs will require infusion of clotting factors. For hemophilia A and von Willebrand's disease, 1.5 U/kg/h; for hemophilia B, 0.75 U/kg/h.

Emergence

 

The tourniquet is deflated around the time of emergence. In patients with moderate-to-severe lung disease, controlled ventilation should be continued until after the lactic acid that has accumulated in the leg has been metabolized (3–5 min), because these patients may be unable to increase ventilation to buffer this acid load.

Blood and fluid requirements

IV: 14–16 ga × 1
NS/LR @ maintenance during the case, and 5–10 mL/kg bolus prior to tourniquet deflation

A tourniquet blocks intraop blood loss. When it is deflated, prepare for a 1–2 U blood loss over the ensuing h; more if the posterior tibial artery has been damaged in the dissection. Avoid under-resuscitation.

 

Control of blood loss

Tourniquet

Inflation pressure is typically 100 mmHg + systolic pressure. Maximum tourniquet time is 2 h, followed by a 30 min reperfusion interval, if further tourniquet time is necessary.

 

Monitoring

Standard monitors (see p. B-1).

 

 

 

± CVP line

A CVP line is indicated if monitoring the CVP trend is expected to affect anesthetic care.

 

 

± Arterial line

Additional monitoring (CVO2Sat, PA cath, TEE) may be indicated in special cases.

 

Positioning

[check mark] and pad pressure points.
[check mark] eyes.

In rheumatoid arthritic patients, meticulous padding of the extremities is mandatory.

 

Complications

Posterior tibial artery trauma
Peroneal nerve palsy

A 20% ↓MAP is common on tourniquet deflation. Additional crystalloid (5–10 mL/kg) may be necessary to replace edema fluid and blood loss to the leg.

 

P.1028

Postoperative

Complications

Hemorrhage from the posterior tibial artery

[check mark] surgical drain output.

 

Peroneal nerve palsy → foot drop

Examine patient for evidence of neurologic dysfunction and notify surgeons as necessary.

 

Tourniquet-related nerve injury

 

 

Post-tourniquet syndrome (PTS)

PTS is a self-limiting condition in which the affected limb is edematous, pale, and weak.

Pain management

Neuraxial regimens:

 

 

·         Epidural anesthesia

Epidural bupivacaine 0.0125% infused at 6–8 mL/h with hydromorphone 50 mcg/mL infused at 100–250 mcg/h provides good analgesia.
Prior to removal of the epidural catheter a 0.2 mg bolus of hydromorphone may be given. Epidural catheters are typically removed on the morning of postop day 2. Low-molecular-weight heparin may be started 2 h after catheter removal.

 

·         SAB

Intrathecal morphine 0.2–0.3 mg provides analgesia for up to 24 h. May be administered along with bupivacaine for surgical anesthesia.

 

Peripheral regimens:

 

 

·         Single-shot peripheral nerve block (femoral or combined femoral/sciatic block)

These nerves may be blocked preop or postop as a pain rescue measure. A typical dose for each nerve is 20 mL of 0.5% bupivacaine or 0.75% ropivacaine.

 

·         CPNB


Systemic regimens:

Continuous infusion of bupivacaine 0.125% through a standard infusion pump or a portable/disposable pump. Foley catheters are not required with peripheral nerve catheters.
Oral pain management with acetaminophen should be initiated immediately postoperatively (if not contraindicated).
Patient-controlled analgesia (PCA) with IV morphine or hydromorphone may be initiated as alternative to neuraxial blocks or to supplement peripheral regimens.

Tests

Hct; other studies as indicated.

Patients with coagulopathies require replacement therapy for 6–10 d.

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Suggested Readings

  1. Choi PT, Bhandari M, Scott J, et al: Epidural analgesia for pain relief following hip or knee replacement. Cochrane Database Syst Rev2003; 3:CD003071.
  2. Epps CH Jr, ed: Complications in Orthopaedic Surgery,3rd edition. JB Lippincott, Philadelphia: 1994.
  3. Fowler SJ, Symons J, Sabato S, et al: Epidural analgesia compared with peripheral nerve blockade after major knee surgery: a systematic review and meta-analysis of randomized trials. Br J Anaesth2008; 100(2):154–64.
  4. Kuper M, Rosenstein A: Infection control in total knee and total hip arthroplasties. Am J Orthop2008; 37(1):E2–5.
  5. Rosenberg AG: Anesthesia and analgesia protocols for total knee arthroplasty. Am J Orthop2006; 35(7 Suppl):23–6.
  6. Scuderi GR: Preoperative planning and perioperative management for minimally invasive total knee arthroplasty. Am J Orthop2006; 35(7 Suppl):4–6.