Anesthetic Techniques and Their Clinical Application for Specific Orthopedic Procedures

  • Ottokar Stundner
  • Cephas P. Swamidoss


Regional anesthetic and analgesic techniques represent the cornerstones of orthopedic anesthesia; their development and advancement have established new possibilities and have allowed orthopedic surgery to become more available to more patients with comorbidities. While widely used at the Hospital for Special Surgery, variations of regional anesthetic approaches have to be tailored to individual patient comorbidities, preferences, anatomic variations as well as to surgical cofactors. In this chapter we discuss how regional anesthesia can provide focused and sustained pain relief for patients undergoing orthopedic surgery. We further elaborate on how the choice of specific anesthetics and techniques plays a key role in the successful conduct of regional anesthesia. Despite its benefits, the possibility of complications and contraindications must be kept in mind in order to minimize potential harm.


Brachial Plexus Nerve Block Regional Anesthesia Total Shoulder Arthroplasty Saphenous Nerve 
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  1. 1.
    Rosenberg PH, Veering BT, Urmey WF. Maximum recommended doses of local anesthetics: a multifactorial concept. Reg Anesth Pain Med. 2004;29:564–75. discussion 524.PubMedGoogle Scholar
  2. 2.
    Wedel DJ, Horlocker TT. Regional anesthesia in the febrile or infected patient. Reg Anesth Pain Med. 2006;31:324–33.PubMedCrossRefGoogle Scholar
  3. 3.
    Hebl JR, Niesen AD. Infectious complications of regional anesthesia. Curr Opin Anaesthesiol. 2011;24:573–80.PubMedCrossRefGoogle Scholar
  4. 4.
    Gritsenko K, Marcello D, Liguori GA, Jules-Elysee K, Memtsoudis SG. Meningitis or epidural abscesses after neuraxial block for removal of infected hip or knee prostheses. Br J Anaesth. 2011;108:485–90.PubMedCrossRefGoogle Scholar
  5. 5.
    Horlocker TT, Wedel DJ, Rowlingson JC, Enneking FK, Kopp SL, Benzon HT, Brown DL, Heit JA, Mulroy MF, Rosenquist RW, Tryba M, Yuan CS. Regional anesthesia in the patient receiving antithrombotic or thrombolytic therapy: American society of regional anesthesia and pain medicine evidence-based guidelines (third edition). Reg Anesth Pain Med. 2010;35:64–101.PubMedCrossRefGoogle Scholar
  6. 6.
    Horlocker TT. Regional anaesthesia in the patient receiving antithrombotic and antiplatelet therapy. Br J Anaesth. 2011;107 Suppl 1:96–106.CrossRefGoogle Scholar
  7. 7.
    Hebl JR, Horlocker TT, Kopp SL, Schroeder DR. Neuraxial blockade in patients with preexisting spinal stenosis, lumbar disk disease, or prior spine surgery: efficacy and neurologic complications. Anesth Analg. 2010;111:1511–9.PubMedCrossRefGoogle Scholar
  8. 8.
    Wolfe JW, Butterworth JF. Local anesthetic systemic toxicity: update on mechanisms and treatment. Curr Opin Anaesthesiol. 2011;24:561–6.PubMedCrossRefGoogle Scholar
  9. 9.
    Weinberg GL. Treatment of local anesthetic systemic toxicity (LAST). Reg Anesth Pain Med. 2010;35:188–93.PubMedCrossRefGoogle Scholar
  10. 10.
    Neal JM, Bernards CM, Butterworth 4th JF, Di Gregorio G, Drasner K, Hejtmanek MR, Mulroy MF, Rosenquist RW, Weinberg GL. ASRA practice advisory on local anesthetic systemic toxicity. Reg Anesth Pain Med. 2010;35:152–61.PubMedCrossRefGoogle Scholar
  11. 11.
    Corman SL, Skledar SJ. Use of lipid emulsion to reverse local anesthetic-induced toxicity. Ann Pharmacother. 2007;41:1873–7.PubMedCrossRefGoogle Scholar
  12. 12.
    Picard J, Ward SC, Zumpe R, Meek T, Barlow J, Harrop-Griffiths W. Guidelines and the adoption of 'lipid rescue' therapy for local anaesthetic toxicity. Anaesthesia. 2009;64:122–5.PubMedCrossRefGoogle Scholar
  13. 13.
    Jacob AK, Mantilla CB, Sviggum HP, Schroeder DR, Pagnano MW, Hebl JR. Perioperative nerve injury after total hip arthroplasty: regional anesthesia risk during a 20-year cohort study. Anesthesiology. 2011;115:1172–8.PubMedGoogle Scholar
  14. 14.
    Brull R, McCartney CJ, Chan VW, El-Beheiry H. Neurological complications after regional anesthesia: contemporary estimates of risk. Anesth Analg. 2007;104:965–74.PubMedCrossRefGoogle Scholar
  15. 15.
    Urmey WF. Using the nerve stimulator for peripheral or plexus nerve blocks. Minerva Anestesiol. 2006;72:467–71.PubMedGoogle Scholar
  16. 16.
    Antonakakis JG, Ting PH, Sites B. Ultrasound-guided regional anesthesia for peripheral nerve blocks: an evidence-based outcome review. Anesthesiol Clin. 2011;29:179–91.PubMedCrossRefGoogle Scholar
  17. 17.
    Bigeleisen P, Wilson M. A comparison of two techniques for ultrasound guided infraclavicular block. Br J Anaesth. 2006;96:502–7.PubMedCrossRefGoogle Scholar
  18. 18.
    Barrington MJ, Snyder GL. Neurologic complications of regional anesthesia. Curr Opin Anaesthesiol. 2011;24:554–60.PubMedCrossRefGoogle Scholar
  19. 19.
    Ilfeld BM. Continuous peripheral nerve blocks: a review of the published evidence. Anesth Analg. 2011;113:904–25.PubMedCrossRefGoogle Scholar
  20. 20.
    Partridge BL, Katz J, Benirschke K. Functional anatomy of the brachial plexus sheath: implications for anesthesia. Anesthesiology. 1987;66:743–7.PubMedCrossRefGoogle Scholar
  21. 21.
    Winnie AP. Interscalene brachial plexus block. Anesth Analg. 1970;49:455–66.PubMedCrossRefGoogle Scholar
  22. 22.
    Urmey WF, Gloeggler PJ. Pulmonary function changes during interscalene brachial plexus block: effects of decreasing local anesthetic injection volume. Reg Anesth. 1993;18:244–9.PubMedGoogle Scholar
  23. 23.
    Plit ML, Chhajed PN, Macdonald P, Cole IE, Harrison GA. Bilateral vocal cord palsy following interscalene brachial plexus nerve block. Anaesth Intensive Care. 2002;30:499–501.PubMedGoogle Scholar
  24. 24.
    Sinha SK, Abrams JH, Barnett JT, Muller JG, Lahiri B, Bernstein BA, Weller RS. Decreasing the local anesthetic volume from 20 to 10 ml for ultrasound-guided interscalene block at the cricoid level does not reduce the incidence of hemidiaphragmatic paresis. Reg Anesth Pain Med. 2011;36:17–20.PubMedCrossRefGoogle Scholar
  25. 25.
    Benumof JL. Permanent loss of cervical spinal cord function associated with interscalene block performed under general anesthesia. Anesthesiology. 2000;93:1541–4.PubMedCrossRefGoogle Scholar
  26. 26.
    Gautier P, Vandepitte C, Ramquet C, DeCoopman M, Xu D, Hadzic A. The minimum effective anesthetic volume of 0.75 % ropivacaine in ultrasound-guided interscalene brachial plexus block. Anesth Analg. 2011;113:951–5.PubMedGoogle Scholar
  27. 27.
    Liu SS, Gordon MA, Shaw PM, Wilfred S, Shetty T, Yadeau JT. A prospective clinical registry of ultrasound-guided regional anesthesia for ambulatory shoulder surgery. Anesth Analg. 2010;111:617–23.PubMedCrossRefGoogle Scholar
  28. 28.
    Guzeldemir ME. Pneumothorax and supraclavicular block. Anesth Analg. 1993;76:685.PubMedCrossRefGoogle Scholar
  29. 29.
    Perlas A, Lobo G, Lo N, Brull R, Chan VW, Karkhanis R. Ultrasound-guided supraclavicular block: outcome of 510 consecutive cases. Reg Anesth Pain Med. 2009;34:171–6.PubMedCrossRefGoogle Scholar
  30. 30.
    Chan VW, Perlas A, Rawson R, Odukoya O. Ultrasound-guided supraclavicular brachial plexus block. Anesth Analg. 2003;97:1514–7.PubMedCrossRefGoogle Scholar
  31. 31.
    Chin KJ, Singh M, Velayutham V, Chee V. Infraclavicular brachial plexus block for regional anaesthesia of the lower arm. Anesth Analg. 2010;111:1072.PubMedCrossRefGoogle Scholar
  32. 32.
    Fredrickson MJ, Wolstencroft P, Kejriwal R, Yoon A, Boland MR, Chinchanwala S. Single versus triple injection ultrasound-guided infraclavicular block: confirmation of the effectiveness of the single injection technique. Anesth Analg. 2010;111:1325–7.PubMedCrossRefGoogle Scholar
  33. 33.
    Chin KJ, Handoll HH. Single, double or multiple-injection techniques for axillary brachial plexus block for hand, wrist or forearm surgery in adults. Cochrane Database Syst Rev. 2011;7:CD003842.PubMedGoogle Scholar
  34. 34.
    De Tran QH, Clemente A, Finlayson RJ. A review of approaches and techniques for lower extremity nerve blocks. Can J Anaesth. 2007;54:922–34.PubMedCrossRefGoogle Scholar
  35. 35.
    Atanassoff PG, Weiss BM, Brull SJ, Horst A, Kulling D, Stein R, Theiler I. Electromyographic comparison of obturator nerve block to three-in-one block. Anesth Analg. 1995;81:529–33.PubMedGoogle Scholar
  36. 36.
    Paul JE, Arya A, Hurlburt L, Cheng J, Thabane L, Tidy A, Murthy Y. Femoral nerve block improves analgesia outcomes after total knee arthroplasty: a meta-analysis of randomized controlled trials. Anesthesiology. 2010;113:1144–62.PubMedCrossRefGoogle Scholar
  37. 37.
    Saranteas T, Anagnostis G, Paraskeuopoulos T, Koulalis D, Kokkalis Z, Nakou M, Anagnostopoulou S, Kostopanagiotou G. Anatomy and clinical implications of the ultrasound-guided subsartorial saphenous nerve block. Reg Anesth Pain Med. 2011;36:399–402.PubMedCrossRefGoogle Scholar
  38. 38.
    Richman JM, Liu SS, Courpas G, Wong R, Rowlingson AJ, McGready J, Cohen SR, Wu CL. Does continuous peripheral nerve block provide superior pain control to opioids? A meta-analysis. Anesth Analg. 2006;102:248–57.PubMedCrossRefGoogle Scholar
  39. 39.
    Heavner JE. Local anesthetics. Curr Opin Anaesthesiol. 2007;20:336–42.PubMedCrossRefGoogle Scholar
  40. 40.
    Berde C, Strichartz G. Local anesthetics. In: Miller R, editor. Miller’s anesthesia. 7th ed. Philadelphia, PA: Churchill Livingstone; 2009. p. 913–39.Google Scholar
  41. 41.
    Forster JG, Rosenberg PH. Revival of old local anesthetics for spinal anesthesia in ambulatory surgery. Curr Opin Anaesthesiol. 2011;24:633–7.PubMedCrossRefGoogle Scholar

Copyright information

© Springer New York 2014

Authors and Affiliations

  1. 1.Department of Anesthesiology, Perioperative Medicine, and Intensive Care MedicineParacelsus Medical UniversitySalzburgAustria
  2. 2.Department of AnesthesiologyHospital for Special Surgery, Weill Cornell Medical CollegeNew YorkUSA

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