Mod10: Orthopedic surgery - Surgery on the Lower Extremities Flashcards
Surgery on the Lower Extremities - Surgery to the Hip and Femur
Hip fractures
Patient population/Pre-op considerations:
Elderly
Many patients are frail and elderly
Morbidity and mortality
Mortality rate following hip fx up to 10% during initial hospitalization
25% within one year following fx
Co-morbidities
Many have a number of co-morbidities (CAD, cerebrovascular disease, COPD, DM, OSA)
Dehydrated
Many are dehydrated from inadequate oral intake
Hemoconcentration can lead to a deceptively normal Hct or Hgb preoperatively
Surgery to the Hip and Femur - Anesthetic techniques
GA versus regional (SAB or epidural):
Should take into consideration the type of reduction and fixation to be used
This depends on fx site, degree of displacement, preoperative functional status of patient, surgeon preference
Surgery to the Hip and Femur - Anesthetic techniques
Regional (SAB or epidural) technique:
15 RCTs showed decreased in postop DVT and 1-month mortality with RA…but these benefits do not persist past 3 months
You can see less postoperative delirium and postop cognitive dysfunction with RA if you use minimal sedation with the regional technique
Surgery to the Hip and Femur - Anesthetic techniques
Spinal anesthesia
advantage/ best LA & their benefits:
A spinal or epidural, with or without GA, has the advantage of enhanced postoperative pain control
If you use a spinal, hypobaric or isobaric local anesthetics are ideal for positioning, since the patient can lie on the nonoperative hip for the placement of the SAB and the surgery
Surgery to the Hip and Femur - Hip Arthroplasty
Longer, more invasive procedures
include:
Hemi-arthroplasties & Total Hip Arthroplasties (THA)
are long and more invasive procedures
usually done in lateral decubitus position.
Surgery to the Hip and Femur - Hip Arthroplasty
Blood loss:
Both hemiarthroplasties and total hip arthroplasties have greater blood loss
Can result in significant hemodynamic changes, especially if cement is used
Make sure you have large bore IV and type and cross preop
Surgery to the Hip and Femur - Hip Arthroplasty
OA, RA, avascular necrosis
important intubation conerns:
Most patients having a THR has OA, RA, or avascular necrosis
Mentioned RA before – discussed their limited cervical range of motion
Atlantoaxial subluxation can be diagnosed with x-ray and during intubation
This can lead to protrusion of the odontoid process into the foramen magnum
=> this can impede vertebral blood flow and compress the spinal cord and brain
Flexion and extension lateral radiographs of the c-spine in patients with severe RA should be obtained before surgery
=> these would be patients who have RA that is severe enough to require methotrexate, steroids, or immune therapy
If atlantoaxial instability is present –> need to intubate with inline stabilization using a Glidescope, c-mac, or fiberoptic laryngoscopy
Surgery to the Hip and Femur - Hip Arthroplasty
THA consists of several steps:
Femoral head is dislocated and removed
There is reaming of the femur and insertion of a femoral component into the femoral shaft
Surgery to the Hip and Femur - Total Hip Arthroplasty (THA)
Positioning
Lateral decubitus or supine
Surgery to the Hip and Femur - Total Hip Arthroplasty (THA)
Potential for complications:
Bone cement implantation syndrome
Hemorrhage
Venous thromboembolism
Surgery to the Hip and Femur - Total Hip Arthroplasty (THA)
Types of specific procedures:
Hip surfacing arthroplasty
Bilateral arthroplasty
Revision arthroplasty
Minimally invasive arthroplasty
Hip arthroscopy
Surgery to the Hip and Femur - Total Hip Arthroplasty (THA) - Types
Bilateral arthroplasty
how does procedure on 1st hip influence second procedure?
Second procedure can be done safely as long as there is no occurrence of significant PE after the first femoral component is inserted
Be sure to be in good communication with the surgeon
If there are significant hemodynamic changes or instability during first hip, then the second hip should be postponed
Surgery to the Hip and Femur - Total Hip Arthroplasty (THA) - Types
Revision arthroplasty
blood loss compared to original procedure:
Can have much larger blood loss than original surgery
Can also take longer than routine arthroplasty
Depends on a number of factors, including surgeon skill
Consider preop autologous donation; and intraop salvage techniques
Some studies indicate decreased blood loss during hip surgery if regional rather than general technique used
Exact mechanism is not clear
Surgery to the Hip and Femur- Total Hip Arthroplasty (THA) - Types
Closed reduction of hip dislocation
can be accomplished with which type of anesthetic?
Usually can be accomplished with very brief anesthetic
Often induce with Propofol and mask patient with gas
May need to use Sux to facilitate reduction if hip musculature severely contractured
Surgery to the Hip and Femur
Total Knee Arthroplasty
Position/How is blood loss minimized?
Supine position
Blood loss usually minimized with use of TQ
Not all surgeons use a TQ
Surgery to the Hip and Femur
Total Knee Arthroplasty
Anesthesia Techniques:
GA
Neuraxial
Surgery to the Hip and Femur - Total Knee Arthroplasty - Anesthesia Techniques
GA with LMA or ETT
choice based on:
As always, make sure your patient is a candidate for LMA
Evaluate risk for aspiration
Surgery to the Hip and Femur - Total Knee Arthroplasty - Techniques
Neuraxial:
If cooperative, patients can tolerate neuraxial technique plus sedation
Surgery to the Hip and Femur - Total Knee Arthroplasty
Postop pain
Facilitated by preop placement of:
Lumbar epidural or Perineural catheter
Post-op pain is typically more severe than pain following hip arthroplasty
Effective postop analgesia facilitates early physical rehabilitation to maximize postoperative ROM and prevent joint adhesions following knee replacement
Need to balance pain control and patient comfort with the need for patient who is alert and cooperative enough to start their postoperative rehab program
Epidural analgesia is useful for those patient having bilateral knee replacements