Whether they are anticipating a relatively minor procedure to the foot or hand, or a total joint replacement, individuals considering elective orthopedic surgery are often advised to select an institution where surgeons perform large numbers of the procedures in question. At HSS, successful outcomes also result from close collaboration across specialties, including anesthesiology and pain management.
HSS anesthesiologists, together with colleagues in surgery, pain management, nursing and physical therapy, provide comprehensive care for patients from the period leading up to surgery until after they are discharged from the hospital, according to Gregory A. Liguori, MD, Anesthesiologist-in-Chief. This includes preoperative evaluation, selection of optimal anesthesia during surgery, and management of postoperative discomfort during recovery.
Depending on the nature of their procedure, patients undergoing orthopedic surgery receive either general anesthesia, in which medications are administered to induce a state of unconsciousness, or a localized type of regional anesthesia. Neuraxial anesthesia, an epidural or a spinal block, involves techniques that numb the lower half of the body. Regional anesthesia may also be used to numb the shoulder and arm, permitting upper extremity surgery without the need for general anesthesia. With regional anesthesia, patients often choose to be sedated during the procedure, but also may have the option to remain fully or somewhat awake.
“At HSS, where we perform significantly more hip and knee replacements annually than other leading orthopedic hospitals, 98% of patients undergoing these surgeries receive regional anesthesia,” says Dr. Liguori. “Nationwide, that figure is closer to 25%.”
Regional anesthesia offers an array of advantages that include less nausea and vomiting following surgery, as well a reduced risk of respiratory or cardiac problems. This form of anesthesia may also be associated with lower infection rates following surgery. “When neuraxial anesthesia is administered, the blood vessels in the lower extremity dilate, “Dr. Liguori explains. “This means more oxygen is delivered to the bone and surrounding tissues, reducing the likelihood of infection. Moreover, because neuraxial anesthesia lowers the patient’s blood pressure (which is carefully monitored throughout surgery) and therefore reduces operative bleeding, the surgeon is able to operate more quickly. This may also lower infection risk.
At HSS, the infection rate is further minimized by measures in place in the operating rooms: These include specially designed hooded protective suits worn by surgeons and a high-tech air filtration system with laminar flow panels that keep clean air moving rapidly through the operating room in one direction.
For some operations, including surgeries in young patients and/or those involving the spine, general anesthesia is still necessary, Dr. Liguori says. In these cases, close monitoring during and after surgery helps minimize any anesthesia-related discomfort or complications.
During the immediate postoperative period, some patients with serious medical conditions are cared for in a dedicated Orthopedic Special Care Unit, the first and only ICU in the country dedicated solely to orthopedic critical care issues. Anesthesiologists who are also trained in critical care medicine are on staff in this unique, specialized recovery unit. Members of this team – which includes physician assistants and nurse practitioners – are available around the clock to address any concerns that arise.
Because some patients scheduled to undergo surgery at HSS are already taking medication – including opioids – to control their pain, a preoperative evaluation may be necessary. For patients currently on opioid medication, the goal is to reduce the amount taken preoperatively and minimize the amount prescribed postoperatively, according to Dr. Liguori. This assessment can also alert the anesthesiologist to considerations, such as obesity or sleep apnea, that may influence how anesthesia and pain will be addressed.
Regardless of the type of anesthesia used during a procedure, controlling postsurgical pain is key to the patient’s recovery. In addition to the psychological importance of feeling better, the sooner a patient can engage in a rehabilitation program, the better the outcome. “Traditionally, orthopedists relied on opioid drugs,” Dr. Liguori explains, “including morphine, fentanyl, and combinations of acetaminophen with oxycodone or hydrocodone.” However, excessive reliance on opioids has led to problems in some individuals, including respiratory and gastrointestinal complications, development of hyperalgesia (a condition in which pain is experienced more acutely than it is by those without the condition), and addiction.
In response to the growing awareness of these problems, Dr. Liguori and his colleagues have adopted a multimodal approach to pain relief that significantly minimizes the need for opioids, which reduces or eliminates opioid side effects.
“With multimodal pain management, we give several different medications in combination. For example, the patient who is given an epidural or spinal block for surgery needs effective pain relief as the effects of anesthesia wear off,” he says. In the case of knee replacement, the surgeon may administer a periarticular injection during the procedure, in which medication that addresses pain is delivered directly to the soft tissues that surround the joint. A nerve block with a long-acting drug such as bupivacaine can also be injected by the anesthesiologist around the nerves that bring sensation to the knee. The same patient may also receive acetaminophen (which may be given as an oral drug or intravenously), a nonsteroidal anti-inflammatory drug like ketorolac or celecoxib, medications that can address nerve pain (such as gabapentin), and dexamethasone (a steroid). Use of these measures in the right combination can minimize and sometimes eliminate the need for opioids, and still provide the patient with very effective pain relief.
The use of ultrasound guidance with nerve blocks is an especially important technological advance that improves the performance of regional anesthetics. In the past, in patients undergoing knee replacement, anesthesiologists would sometimes administer a nerve block to the accessible and easy-to-locate femoral nerve at the top of the leg, which supplies sensation to most of the limb, including the knee. Although this offered effective pain relief, the nerves that control motor function were also blocked. Now, using ultrasound-guided nerve blocks, anesthesiologists are able to administer medications to a more local area by selectively injecting the sensory branches of the femoral nerve. By selectively blocking the sensory branch of the nerve using ultrasound guidance, while sparing the motor branch of the nerve, the area of surgery is numbed, pain relief is afforded and sufficient motor function is preserved to allow the patient to move the joint (and actively participate in rehabilitation) without experiencing significant pain in the knee.
“This represents a huge advance, since patients can now not only get up and walk around comfortably the same day as their surgery, but also begin rehabilitation more quickly,” says Dr. Liguori. “We have also been able to add some medications that extend the duration of the effect of these blocks, from around 8 to 12 hours to up to 24 to 48 hours.” Nerve blocks guided by ultrasound may also be used in surgeries for the foot, ankle and arm, including total shoulder replacement as well as other shoulder surgeries.
Effective pain control has multiple benefits, including enabling patients to begin rehabilitation sooner – which has a direct effect on shortening hospital stays. Some surgeries that used to require hospitalization are now being performed on a same-day discharge basis. For most major joint replacement surgeries, patients can return home after two to three days in the hospital versus an average stay of eight days before the advent of current pain management techniques.
Following orthopedic surgery at HSS, the majority of patients achieve successful control of their pain with an individualized regimen of medication. For the small number of patients who continue to have pain that is not well controlled in the short-term after surgery, members of the Recuperative Pain Medicine Service are available to fine-tune medication, using the multimodal approach described. This technique is also used by specialists in the Pain Management Division, who may prescribe different combinations of medications and interventions to address longer-term pain.
Citing the surprising results of a University of Chicago study in which individuals undergoing elective surgery expressed more concern about pain than about the success of their surgery, Dr. Liguori notes, “This is why we developed the comprehensive pain management program – to respond to that concern at every stage of treatment and recovery.”
To learn more, see our video series, Anesthesia Frequently Asked Questions.
Summary by Nancy Novick