Management of surgical procedures common in men. Part 2: orthopedic procedures Keywords Lumbar laminectomy Lumbar spinal fusion Shoulder arthroplasty Hip arthroplasty
Kendal Miller, Wayne Alongi and Laura S. Bonanno Abstract Musculoskeletal disorders and injuries are common in men and often result in the need for surgical procedures. Orthopedic procedures rank in the top ten of the most common surgerical procedures performed in men. This article outlines the surgical and anesthetic implications and management of common orthopedic surgical procedures including: lumbar laminectomy, lumbar spinal fusion, shoulder arthroplasty, hip arthroplasty, and knee arthroplasty. ß 2010 WPMH GmbH. Published by Elsevier Ireland Ltd.
Kendal Miller, MN, CRNA Louisiana State University Health Sciences Center School of Nursing, New Orleans, USA Wayne Alongi, MN, CRNA Louisiana State University Health Sciences Center School of Nursing, New Orleans, USA Laura Bonanno, DNP, CRNA Louisiana State University Health Sciences Center School of Nursing, New Orleans, USA E-mail: [email protected]
Musculoskeletal disorders and injuries are the indication for the majority of surgical procedures performed in men. According to National Healthcare Statistics for 2006, musculoskeletal complaints ranked second among all symptoms that presented to physicians in the USA . Nearly a quarter of all Americans have some orthopedic disorder. The diagnosis and treatment of these disorders costs the healthcare system nearly $850 billion (7.7% of the gross domestic product) yearly . Common orthopedic surgical procedures in men include: lumbar laminectomy, lumbar spinal fusion, shoulder arthroplasty, hip replacement and knee arthroplasty. The purpose of this review is to outline the current surgical techniques, anesthetic options, and peri-operative management of these procedures.
Spinal surgery Lumbar spinal back pain was listed as the number one reason that patients visited a physician between 1998 and 2004 . Conditions such as spinal stenosis, herniated discs,
Vol. 7, No. 4, pp. 406–412, December 2010
and spondylolisthesis are known to disrupt the normal anatomical integrity of the spine. Any condition that alters the normal protective anatomy of the spine can cause pressure on surrounding nerves. When pressure is applied to nerves the patient experiences pain. Usually, nonsurgical medical treatment is sought for relief of this back pain initially. When that treatment fails to provide adequate pain relief, surgical treatment is considered. Back pain that is unresolved by nonsurgical medical treatment is the leading indication for lumbar spine surgical intervention . Removal of the insulting tissue or bone should relieve the pressure and associated pain.
Lumbar laminectomy Lumbar laminectomy is the complete removal of the lamina . A 1 inch vertical midline incision is made at the targeted level. Tissue layers are traversed down to the level of suspected disease and the area of concern is confirmed by visual inspection and radiography. Microscopic visualization aids the surgeon in the removal of bone and/or disc material. The wound layers are sutured closed when hemeostasis is established and a drain may be placed in the epidural space. The morbidity
ß 2010 WPMH GmbH. Published by Elsevier Ireland Ltd.
Original article and mortality rates are <5% and 0.5%, respectively . Surgical time is estimated at 1–2 hours for a single level with an additional 0.5–1 hour for each additional level . Depending on the extent of the laminectomy, the surgeon may also perform a spinal fusion to protect the integrity and stability of the spine. Abnormal movement of the spine applies pressure to spinal nerves resulting in the patient experiencing pain. Such pain can be reduced or alleviated when the unstable area is immobilized.
Lumbar spinal fusion Lumbar spinal fusion results in the immobilization of segments of the lumbar spine and is the treatment for chronic lower back pain, segmental lumbar instability, spondylolisthesis, and instability for extensive laminectomy or facetectomy . A 1-inch posterior midline incision is made at the targeted level. The unstable area of the spine that is believed to be contributing to pain is fused together with the aid of plates and screws. The movement of the unstable spine segment is reduced or isolated in an attempt to resolve the associated pain. A posterior approach is most commonly used; however, more complex cases might require a combined anterior and posterior approach with instrumentation. Surgical time is estimated at 3–4 hours for single levels and an additional 1 hour for each additional level . The wound layers are sutured closed once hemeostasis is established and a drain may be placed in the epidural space. The morbidity and mortality rates for this procedure are 10–20% and 0–5%, respectively .
Anesthetic options General anesthesia is indicated for these procedures. However, the technique used may need to be varied if motor evoked potentials (MEPs) are being recorded. MEPs monitor the
integrity of the descending motor pathway during neurosurgical or orthopedic procedures. Volatile agents (sevoflurane, desflurane and isoflurane) are known to interfere with MEPs and are best avoided or used in low doses . Total intravenous anesthesia (TIVA) with propofol is the most appropriate technique to complement the use of MEP monitoring . However, different anesthetic combinations should also be considered (Table 1). If the surgical procedure necessitates the patient being in the prone position, the use of a wire reinforced endotracheal (ET) tube should be considered to prevent tube kinking and occlusion . Patient positioning (prone), surgical time and the potential for postoperative neurological damage limit the use of regional anesthesia.
Preoperative management Patients presenting for spinal surgery often have associated medical conditions involving the respiratory, cardiovascular, musculoskeletal, and gastrointestinal systems. Patients with low back pain are significantly more likely to smoke, be overweight or obese, drink heavily and be diagnosed with depression, anxiety, and insomnia . A thorough airway examination should be conducted to identify a potentially difficult airway. Pre-operative assessment should also include a thorough neurological examination to include any history of bowel or bladder dysfunction. Patients taking medications such as non-steroidal antiinflammatory drugs (NSAIDs) and acetylsalicylic acid (ASA) at home for pain should be instructed to stop taking them at least 1 week prior to surgery . If patients have been medically managed using steroid therapy within 6 months, an intra-operative dose of steroids should be administered. Complete blood count (CBC), prothrombin time (PT), partial thromboblastin time (PTT), and international normal-
Table 1 Recommendations for anesthetic technique for MEPs Compatible agents
Opioids Etomidate Ketamine Low-dose propofol
Volatile inhalation agents Neuromuscular blockade with loss of > 2 twitches in the train of four Nitrous oxide >50% Induction doses of thiopental
Source: Karlet  p. 331 – with permission pending.
Vol. 7, No. 4, pp. 406–412, December 2010
Original article ized ratio (INR), should be current and within acceptable limits prior to surgery. Other laboratory tests may be indicated based on the patient’s co-morbidities. When surgical procedure time is known to be extensive, the potential for excessive blood loss should be anticipated. Multiple operative levels require more surgical time and greater opportunity for increased blood loss. It is, therefore, necessary to have two units of blood on standby as needed . Intra-operative blood salvage may reduce blood loss and help maintain patient blood volume.
Intra-operative management The patient is placed in the prone position after intubation. Obese patients in the prone position may encounter abdominal compression resulting in decreased venous return and increasing epidural engorgement lending to an increase in operative blood loss . Spinal alignment must be maintained while the patient is in the prone position. There are specific headrests that are used for patients in the prone position to secure the head and maintain the cervical spine in the neutral position. All pressure points should be padded, and the eyes protected. Intra-operative complications include hypotension, hemorrhage, nerve-root injury and blindness. In addition to standard monitors, arterial and central venous pressure lines are helpful for monitoring adequate perfusion pressure, assessing fluid volume status and obtaining laboratory tests. Laboratory tests such as hemoglobin and arterial blood gas levels should be monitored throughout, in order to evaluate blood loss accurately. To prevent ischemic organ damage, caused by hypotension, a mean arterial blood pressure of 60–80 mmHg should be maintained. Urine output in the prone position is not a reliable indicator of fluid volume status. Estimated blood loss (EBL)
is thought to be between 25–1000 ml, depending on the technique used and the number of levels fused .
Postoperative management Blood pressure, heart rate, respirations, oxygen saturation and temperature are monitored postoperatively. Hypotension, despite fluid and blood replacement, can indicate retroperitoneal blood loss and should be reported to the surgeon immediately . Hematocrit and hemoglobin levels should be obtained in the recovery room and compared to the patient’s baseline levels. Postoperative pain is usually managed by patient controlled analgesia and some surgeons will place opiates epidurally prior to closing . The patient’s neurological status should be continually evaluated and compared to that patient’s baseline to determine whether there are any deficits.
Shoulder arthroplasty Shoulder injury and degenerative joint changes are the most common conditions necessitating surgical procedures of the upper extremities in men. More than 50,000 shoulder surgeries are performed yearly in the USA . Trauma to the shoulder and arthritic disease may lead to acromial impingement and tears of the rotator cuff. These injuries cause limited mobility and considerable pain. Rotator cuff injuries and subacromial impingement affect between 5–30% of the population (Table 2) and there is a 3:1 male to female gender difference in surgical procedures performed .
Surgical techniques Surgical intervention is required in shoulder injuries when the joint is damaged by trauma
Table 2 Statistics by procedure.
Age Gender ratio Male: Female Incidence/year Mortality Source: Jaffe & Samuels .
Vol. 7, No. 4, pp. 406–412, December 2010
15–85 3:2 Common 0.5%
15–85 3:2 Common 0–5%
15–40 2:1–4:1 > 50,000 < 1%
> 60 Etiology dependent 250,000 1–2%
> 60 1:1 400,000 <1%
Original article or when medical treatment utilizing steroid injections fails to improve symptoms of degenerative disorders. Procedures involved include both open and arthroscopic repair of the joint and the surgical time is usually 2–3 hours. Repair of the subacromial impingement ‘‘involves shaving of the anterolateral aspect of the undersurface of the acromion (creating more room in the subacromial space)’’ . Blood loss during this repair can be lessened with the use of arthroscopy, however visualization may be decreased. Rotator cuff repair may be achieved by utilizing a direct lateral incision, a mini open approach with arthroscopy or a completely arthroscopic approach . Blood loss is minimalized with arthroscopy but ranges between 200–400 ml when performed openly .
Anesthetic options Regional or general anesthesia can be safely administered for surgical procedures involving the shoulder. A combination of both approaches is usually selected to ensure adequate pain management postoperatively and because of limited access to a patient’s airway during these procedures. An interscalene block is the preferred regional technique, but may be contraindicated due to pulmonary disease and difficulty in assessing neurologic function following the procedure. Muscle relaxants are often necessary during rotator cuff excision and during surgical closure .
Pre-operative management Pre-operative considerations for shoulder procedures are dependent on the patient’s age. Rotator cuff repair is common in younger athletic males as well as in middle-aged adult males. Degenerative and arthritic changes may necessitate surgical procedures in older and elderly men. Age-dependent pre-operative studies should include cardiovascular evaluation as well as standard chemistries and the assurance of proper blood coagulation. Neurologic conditions must be identified in the pre-operative period, as nerve injuries are possible complications. ‘‘When a neurologic condition is identified,’’ strategies such as static splinting of the affected area may be required . Common conditions co-existing with the associated shoulder problems include rheumatoid/
osteoarthritis, diabetes mellitus (DM) and renal failure .
Intra-operative management Intra-operative considerations for shoulder surgical procedures include the proper monitoring of patient vital signs, intravascular volume and blood loss. The inability to utilize tourniquets during these procedures increases the risk of significant blood loss. An arterial line can be used for tight blood pressure control and for monitoring intra-operative hemoglobin levels . The beach chair position is most often employed for shoulder procedures and obviates increased intra-operative anesthesia vigilance. Compression related nerve injuries, as well as venous air emboli, are potential complications related to this position.
Postoperative management Postoperative considerations for shoulder surgery include monitoring for complications and management of pain. Common complications of these procedures include infection (1– 5%), axillary nerve damage (<2%), musculocutaneous nerve damage (<2%) and brachial plexus damage due to positioning . If arthroscopy is employed the extravasation of fluid is also possible. Postoperative pain is usually controlled using the interscalene block and augmented with oral or intravenous narcotics. However, the postoperative evaluation of nerve injuries should be delayed until the interscalene block has worn off. Shoulder immobilizers are employed and the patient must maintain ‘‘no active motion of the shoulder girdle for 2 days to 6 weeks’’ .
Hip arthroplasty As noted in Table 2, there are more than 250000 hip arthroplasties performed in the USA each year . While the majority of hip arthroplasties are performed in patients greater than 60 years old, juvenile rheumatoid arthritis increases the incidence of surgery for patients of all ages . Total hip replacement is generally required in patients with severe arthritic joint changes, hip arthrosis, severe hip dislocation and femoral fractures. Surgery restores patient comfort, joint range of motion and overall level of activity.
Vol. 7, No. 4, pp. 406–412, December 2010
Original article Surgical technique Total hip arthroplasty consists of an anterolateral or posterolateral incision over the hip joint . The damaged femoral head is removed, the femoral neck is prepared by excision and the acetabulum is then prepared to receive the prosthetic replacement . Various metallic prosthetic joint replacements are available. The majority of prosthetics require the use of bone cement for fixation, however to reduce the possibility of a reaction, newer ‘‘cement-less’’ prosthetics have been developed. After the joint has been replaced surgical closure of the incision is completed. The surgical time for this procedure is usually 2–3 hours, and the estimated blood loss is 500–750 ml. If a prior replacement requires revision, surgical time may be extended to 3–6 hours and blood loss may be greater than 1000 ml . The use of regional anesthesia and intra-operative blood salvage may reduce blood loss and help maintain patient blood volume.
Anesthetic options General or regional anesthesia may be employed during total hip arthroplasty, based on the physiological status of the patient. Regional techniques such as spinal or epidural anesthesia are ‘‘well suited to procedures involving the hip,’’ and central neuraxial catheter placement allows for continuous postoperative analgesia . Additionally, Modig et al. concluded that continual epidural anesthesia extended into the postoperative period, ‘‘decreases the frequency of deep vein thrombosis, pulmonary embolus, blood loss and the need for blood transfusion’’ . Other regional techniques such as psoas compartment and lumbar plexus blocks, may be used in conjunction with general anesthesia .
Pre-operative management Due to the large proportion of elderly men receiving total hip arthroplasty, it is essential to provide a thorough pre-operative work-up. Important studies include routine chemistries, coagulation studies, and cardiovascular and respiratory screenings. Coronary artery disease and chronic obstructive pulmonary disease (COPD) are very common age-dependent, coexisting conditions requiring detailed evaluation prior to developing an anesthetic plan.
Vol. 7, No. 4, pp. 406–412, December 2010
Additionally, the anesthetic plan may be altered by pulmonary, cardiovascular and musculoskeletal changes in patients with rheumatoid arthritis. Airway management may be complicated due to arthritic changes in the temporomandibular joint and larynx . Deep vein thrombosis (DVT) prophylaxis with low molecular weight heparin is also often necessary.
Intra-operative management Intra-operative patient management includes standard anesthetic monitoring of vital signs, fluid-volume status and blood loss. Blood salvage techniques and aggressive replacement should be employed. Additionally if a cemented prosthesis is used, the patient must be observed closely for physiological reactions to methyl methacrylate. Exothermic methyl methacrylate reactions produce heat, which can cause extreme bradycardia, leading to cardiac arrest . Additionally, the reaction ‘‘is capable of expanding intramedullary gases and pressures such that fat, air and marrow may be forced into the circulation’’ leading to signs of a venous embolic event . The patient may be positioned supine or lateral decubitus and must be closely monitored for pressurerelated nerve injuries. Compression devices are used intra-operatively to prevent the possible complication of DVT.
Postoperative management Postoperative considerations include pain management, recognition of complications, and joint rehabilitation. Pain may be best managed through the use of neuraxial catheter administration of opiates and local anesthetic. Alternatively patient controlled narcotic analgesia may be utilized. Postoperative patients must be closely monitored for common complications, which include DVT (10–20% with prophylaxis), infection (1–10%), hematoma (<5%), pulmonary embolism (3.4%) and postoperative joint dislocation (3%) . Postoperative joint immobilization is employed using an abduction pillow, followed by intensive physical therapy and joint mobilization over the subsequent 2–3 weeks.
Total knee arthroplasty Total knee replacement is a common lower extremity surgical procedure in men. Over
Original article 400,000 total knee arthroplasties are performed yearly in the USA . Arthritis, both rheumatoid and juvenile, causes degeneration of the knee joint, which causes significant pain and decreased range of motion. Damage to the joint may also occur during occupational trauma and sports injuries. Arthroplasty may also be required in younger men with hemophiliac arthropathy of the knee, a condition where recurrent bleeding inflames and damages the knee joint . When medical treatment, consisting of physical therapy and steroid anti-inflammatory drugs, fails to improve symptoms, minimally invasive arthroscopy may be attempted to repair damaged ligaments or minisical injury. However, if these therapies are unsuccessful, complete arthroplasty is indicated. Osteoarthritis, the most common indication for elective total knee and hip arthroplasty, costs the US economy more than $60 billion per year .
Surgical technique Total knee arthroplasty is accomplished by the surgical exposure of the patella and excision of the femur and tibia. The knee joint is then resurfaced utilizing a metal and plastic prosthesis. Methyl methacrylate bone cement may or may not be used to fix the prosthesis; if used, the patient must be monitored for signs or symptoms of reaction. A tourniquet is used to decrease blood loss, which averages 300– 500 ml. This blood loss may increase to over 950 ml in surgical revisions of prior knee replacement. Knee arthroplasty procedures usually take between 2–3 hours .
Anesthetic options General or regional anesthesia may be used for knee arthroplasty. Spinal anesthesia, along with peripheral nerve blockade, is often utilized as it often results in lower blood loss and better postoperative pain relief. Since a tourniquet is used during this surgical procedure, ‘‘all four nerves (femoral, lateral femoral cutaneous, obturator and sciatic nerves) innervating the leg,’’ must be blocked . A catheter may be placed during lumbar plexus or sciatic blocks to provide continuous postoperative pain relief. Combinations of peripheral and neuraxial anesthesia may perhaps provide the best anesthesia for knee surgery and the subsequent physical therapy and rehabilitation .
Pre-operative management The majority of knee arthroplasties are performed on elderly men; therefore thorough pre-operative assessments must be made. Chemistry, coagulation studies and complete cardiopulmonary assessments should be completed prior to surgery. Additionally, pulmonary function studies and blood gas levels should be obtained in patients with decreased respiratory function. Since rheumatoid arthritis is the most common co-existing condition, a thorough review of patient medications is necessary, paying special attention to steroid and narcotic usage . DVT prophylaxis is necessary, by means of low molecular weight heparin .
Intra-operative management Intra-operative management of knee arthroplasty begins with standard monitoring of vital signs, volume status and blood loss. Blood salvage techniques and replacement are often necessary especially in patients receiving knee joint revisions. Tourniquet management is important, and hemodynamic changes associated with letting down the compression should be watched closely. Tissue injury may occur during tourniquet inflation as well as transient increases in systemic vascular resistance, which can lead to congestive heart failure in patients with compromised cardiopulmonary function . Post tourniquet syndrome may occur when lactic acid, potassium and inflammatory mediators are released into the blood stream after tourniquet release . The patient must be closely monitored, as hypotension, tachycardia and myocardial depression may develop. Signs of DVT, venous air emboli and methyl methacrylate reactions must also be watched for. Sequential compression devices are often implemented to the alternate leg to prevent DVT. Patients are placed in the supine position during arthroplasty, therefore all joints and pressure points must be thoroughly padded to prevent injury.
Postoperative management Knee arthroplasty requires intensive postoperative pain management and physical therapy. Regional techniques and narcotics provide adequate pain relief. Physical therapy begins immediately following surgery through the use of mechanical continuous passive
Vol. 7, No. 4, pp. 406–412, December 2010
Original article motion. Weight is slowly placed on the joint and the patient is taught to walk utilizing the new prosthetic knee. Common postoperative complications consist of DVT (10–20% with prophylaxis; 50–75% without), wound infection and necrosis (5–10%), and patellar dislocation (35%) . Most patients receiving knee arthroplasty enjoy the full range of motion and a complete return to comfortable activity.
knee arthroplasty are among the leading surgical procedures identified in men. As the population of men continues to age, the need for the procedures discussed may far exceed available resources. Health care providers for men need an understanding of the surgical procedures, anesthetic techniques, and pain management options in order to maximize health care for their patients. This article outlines the surgical and anesthetic implications needed to safely manage several common orthopedic surgical procedures
Lumbar laminectomy, lumbar spinal fusion, shoulder arthroplasty, hip arthroplasty, and
References  American Academy of Orthopedic Surgeons et al. The Burden of Musculoskeletal Diseases in the United States: Prevalence, Societal and Economic Cost. Executive Summary. Rosemont, IL: American Academy of Orthopedic Surgeons; 2008. Available at: http://www.boneandjointburden.org.  Jaffe RA, Samuels SI. Anesthesiologist’s Manual of Surgical Procedures. 4th edn. Philadelphia: Lippincott Williams & Wilkins; 2009, 119–27; 938–49; 991–4; 1014–26.  Morgan G, Mikhail M, Murray M. Clinical Anesthesiology. 4th edn. New York: McGraw-Hill; 2006, 146–7; 644.
 Karlet M. Nurse Anesthesia Secrets. St Louis: Elsevier, Mosby; 2005, 294; 330–331.  Strine T, Hootman J. US national prevalence and correlates of low back and neck pain among adults. Arthritis Rheum 2007;5:57–8.  Lynch N, Cofield R, Silbert P, Hermann RC. Neurologic complications after total shoulder arthroplasty. J Shoulder Elbow Surg 1996;53:43–9.  Barash P, Cullen B, Stoelting R. Clinical Anesthesia. 5th edn. Philadelphia: Lippincott Williams & Wilkins; 2006, pp. 1118–1120.  Modig J, Borg T, Karlstro¨m G, Maripuu E, Sahlstedt B. Thromboembolism after total
Vol. 7, No. 4, pp. 406–412, December 2010
hip replacement: Role of epidural and general anesthesia. Anes Analg 1983;62: 174–80.  Fenter TC, Naslund J, Shah MB, Eaddy MT, Black L. The cost of treating the 10 most prevalent diseases in men 50 years of age or older. Am J Manag Care 2006;12(4): S90–8.  Yadeau J, Cahill J, Zawadsky M, Sharrock N, Bottner F. The effects of femoral nerve block in conjunction with epidural anesthesia following total knee arthroplasty. Anesth Analg 2005;101:281–6.