Perioperative Care of the Orthopedic Patient

Foreword to the Second Edition
Preface to the Second Edition
Preface to the First Edition
Contents
Contributors
Part I: Preoperative Considerations
	1: General Principles and Practices of Perioperative Medicine
		Introduction
		Preoperative Consultation
		Goals of the Preoperative Medical Consultation
			Identification of Conditions that Affect Postoperative Outcome
			Optimization of Conditions that May Affect Postoperative Outcome
			The Assessment of Perioperative Risk
			Patient Education and Preventive Practices
		Efficacy of Preoperative Consultation
		Summary
		References
	2: Perioperative Risk Models
		Introduction
		General Risk Assessment Models
		Cardiac Risk Assessment Tools
		Pulmonary Risk Assessment Tools
		Hepatic Risk Assessment Tools
		Venous Thromboembolism Risk Assessment Tools
		Renal/Genitourinary Risk Assessment Tools
		Additional Models
		Discussion and Summary
		Case Study
			How Does One Approach the Perioperative Risk Assessment of Such a Patient?
		References
	3: The Prevalence of Disabling Musculoskeletal Conditions and the Demand for Orthopedic Surgery in the Twenty-First Century
		Introduction
		Incidence of Degenerative Disorders of the Spine
		Incidence of Spine Procedures
		Incidence of Complications After Spine Surgery
			Definition and Classification of Complications
			Study Methodology
			Surgeon-Related Factors
			Procedure-Related Factors
			Patient-Related Factors
		Prevalence of Osteoarthritis and Related Reconstructive Surgeries of the Hip and Knee
		The Incidence of Complications After Total Knee and Total Hip Arthroplasty
			General Trends
			Specific Complications: Medical
				Infection
				Dislocation
				Venous Thromboembolism
				Periprosthetic Fractures
		Summary
		References
	4: The Rheumatic Diseases: A Primer
		Introduction
		Pathological Considerations
		Laboratory Considerations
		The Rheumatic Diseases
			Osteoarthritis (OA)
			Disorders of the Synovium
			Connective Tissue Diseases
			Spondyloarthritis
			Vasculitides
			Metabolic Bone Disease
			Crystal-Induced Arthropathies
			Infectious Arthritis
			Sarcoidosis
		Summary
		References
	5: The Pathophysiologic Events of Total Joint Replacement Surgery
		Introduction
		Pathophysiology of the Bone Cement Syndrome
		Physiologic Effects on Various Organ Systems
			Cardiopulmonary Effects
			Effects in Other Organ Systems
		The Role of Embolic Load
		The Role of Cement
		The Role of Fat Embolization: The Fat Embolism Syndrome
		The Pathophysiology of Spine Fusion Surgery
		Timing of Complications
		Interventions
		Summary
		Case Study
		References
Part II: Anesthesiologic Management
	6: Anesthesia in the Orthopedic Patient
		Introduction
		The Orthopedic Population
			Advanced Age
			Rheumatoid Arthritis
			Osteoarthritis
		Positioning
		Regional Anesthesia
			Mortality
			Postoperative Analgesia and Rehabilitation
			Respiratory Complications
			Postoperative Confusion
			Deep Vein Thrombosis
			Pulmonary Embolism
			Drawbacks to Regional Anesthetics
		Anticoagulation
		Ultrasound-Guided Regional Anesthesia
		Blood Conservation Strategies
			Controlled Hypotension
			Pneumatic Tourniquet
			Cell Salvaging
			Tranexamic Acid
		Enhanced Recovery After Surgery
		Summary
		Case Study
		References
	7: Pediatric Anesthesia for Orthopedic Surgery
		Introduction
		Regional Anesthesia
			The Impact of Regional Anesthesia in the Pediatric Patient
			Safety in Pediatric Regional Anesthesia
				Ultrasound
		Neuraxial Anesthesia
			Neuraxial Anesthesia in Children
			Caudal Epidurals
		Perioperative Care
			Perioperative Blocks and Postoperative Pain Management
		Complications
			Neurological Injury
			Neuraxial Complications
		Pediatrics and Local Anesthesia
		Special Patient Groups and Considerations
			Cerebral Palsy
			Surgery for Scoliosis Correction
			Allergic Reactions
		Summary
		Case Study
		References
	8: Anesthetic Techniques and Their Clinical Application for Specific Orthopedic Procedures
		Introduction
		Local Anesthetics
			Choice of Local Anesthetic
			Drug Dosage
			Latency
			Adjuvants
		Contraindications for the Use of Regional Anesthesia
			Infection
			Coagulation Disorders
			Preexisting Neurological Deficits
		Complications and Side Effects Associated with Regional Anesthesia
			Local Anesthetic Systemic Toxicity
			Neuropathy/Neurological Injury
		Regional Anesthesia Techniques
			Anatomical Landmarks
			Paresthesia Techniques
			Nerve Stimulator
			Ultrasound Guidance
			Catheter Techniques
		Upper Extremity Nerve Blocks
			The Brachial Plexus
			Review of Anatomy
			Interscalene Nerve Block
			Supraclavicular Nerve Block
			Infraclavicular Nerve (Coracoid) Block
			Axillary Nerve Block
		Extremity Nerve Blocks
			The Lumbosacral Plexus
			Review of Anatomy
			Lumbar Plexus Block
			Saphenous Nerve Block
			IPACK Block
			Femoral Nerve Block
			Popliteal Nerve Block
			Ankle Block
		Neuraxial Anesthesia
		Regional Anesthesia for Specific Procedures
			Anesthetic Techniques: Upper Extremity
				Total Shoulder Arthroplasty
				Shoulder Arthroscopy
				Elbow, Forearm, and Hand Surgery
			Anesthetic Techniques: Lower Extremity
				Total Hip Arthroplasty
				Total Knee Arthroplasty
				Knee Arthroscopy
				Foot and Ankle Surgery
			Spine Surgery
		Summary
		Case Study
		References
	9: The Role of the Postanesthesia Care Unit in the Perioperative Care of the Orthopedic Patient
		Introduction
		Recovery from Anesthesia and Fluid/Blood Management
		Pain Management
		Common Complications
			Cardiac Complications
			Respiratory Complications
			Renal Complications
			Obstructive Sleep Apnea
			Patients After Bilateral Joint Arthroplasty and Revision Arthroplasty
			Postoperative Delirium
		Readmission to the PACU
		Summary
		Case Study
		References
	10: Postoperative Pain Management in the Orthopedic Setting
		Introduction
		General Principles of Pain Management
			Pathophysiology of Pain
			Chronic Postoperative Pain
			Variation of Perioperative Pain for Orthopedic Procedures
			Preemptive and Preventive Analgesia
			Multimodal Analgesia
				Systemic Analgesic Techniques
					Opioids
					Intravenous Patient-Controlled Analgesia (PCA)
					Nonsteroidal Anti-inflammatory Drugs (NSAIDs)
					Acetaminophen
					Tramadol and Tapentadol
					Gabapentinoids
					Steroids
					Muscle Relaxants
					Dexmedetomidine
					Ketamine
				Local Anesthesia Infiltration/ Periarticular Injection
					Periarticular Injection
					Liposomal Bupivacaine
				Regional Anesthesia Techniques
					Peripheral Nerve Blockade
				Neuraxial Anesthesia and Analgesia
					Ambulatory Lower Extremity Procedures
					Total Hip and Knee Arthroplasty
				Peripheral Nerve Catheters
			HSS Pain Management for Specific Procedures
				Total Joint Replacement
				Total Hip Arthroplasty
					Quadratus Lumborum Block (QLB)
					Suprainguinal Fascia Iliaca Block (SIFI)
				Total Knee Arthroplasty
				Shoulder Surgery
					Total Shoulder Arthroplasty
					Shoulder Arthroscopies
				Elbow Surgery
				Foot and Ankle Surgery
				Spine Surgery
			Recuperative Pain Model
			Orthopedic Patients with Chronic Pain
			Transitional Pain Service
		Summary
		Case Study
		References
	11: Enhanced Recovery After Surgery (ERAS) Protocols in Orthopedic Patients
		Introduction
		What Is Enhanced Recovery After Surgery?
		Enhanced Recovery After Surgery for Orthopedic Surgery
			Elective Total Hip and Knee Arthroplasty
			Fractured Neck of Femur
			Revision Joint Arthroplasty
			Total Shoulder Arthroplasty
			Spine
		Limitations of ERAS Research Methodology
		Conclusions and Summary
		Case Study
		References
Part III: Medical Management in Specific Clinical Settings
	12: Perioperative Care of the Orthopedic Patient with Connective Tissue Disease
		Introduction
		Rheumatoid Arthritis
		Systemic Lupus Erythematosus
		Spondyloarthropathy
		Ankylosing Spondylitis
		Psoriatic Arthritis
		Medications
			Corticosteroid
			Synthetic DMARDS
			Biologic Agents
			Tofacitinib
		Summary
		Case Study
		References
	13: Perioperative Care of the Orthopedic Patient with Cardiac Disease
		Introduction
		The Identification of Cardiac Conditions Affecting Postoperative Outcome
		The Optimization of Cardiac Conditions Affecting Postoperative Outcome
			Pharmacologic Therapy
			Interventional Therapy
		Postoperative Considerations and Conditions
			Orthopedic Surgery After Coronary Revascularization
			Devices
			Valvular Heart Disease
			Atrial Fibrillation
			Myocardial Ischemia
		Summary
		Case Study
		References
	14: Perioperative Care of the Orthopedic Patient with Chronic Pulmonary Disease
		Introduction
		The Preoperative Evaluation
			Identification of Conditions That Affect Postoperative Pulmonary Outcome
			Chronic Pulmonary Disease
			Pulmonary Arterial Hypertension
			Obesity
			Congestive Heart Failure
			Impairment in Cognitive and Functional Capacity
		The Optimization of Conditions Relevant to Postoperative Pulmonary Outcome
		The Assessment of Perioperative Risk
			Pulmonary Hypertension
			Anesthesia Technique
		Postoperative Considerations
		Summary
		Case Study
		References
	15: Perioperative Care of the Orthopedic Patient with Renal Disease
		Introduction
		Chronic Kidney Disease
		The Preoperative Renal Evaluation
		Renal Function and Postoperative Risk
		Medication Management
		Blood Pressure, Fluid, and Volume Management
		Electrolyte Disturbances
		Hematologic Issues: Anemia
		Hematologic Issues: Uremic Bleeding
		Renal Replacement Therapy: Dialysis and Transplantation
			Hemodialysis Patients
			Peritoneal Dialysis Patients
			Renal Transplant Patients
		Postoperative Renal Considerations
			Acute Kidney Injury
			Hyponatremia
			Hyperkalemia
		Medications and Nephrotoxins
		The Use of Contrast When Imaging Patients with Renal Disease
		Analgesia in Patients with Renal Disease
		Anesthesia in Patients with Renal Disease
		Miscellaneous
		Summary
		Case Studies
			Case 1
			Case 2
		References
	16: Perioperative Care of the Orthopedic Patient with Diabetes Mellitus
		Introduction
		Preoperative Evaluation of the Patient with Diabetes
		Optimization of the Diabetic Patient
		Perioperative Care
		Non-insulin Hypoglycemic Agents
		Insulin
		The Assessment of Perioperative Risk in the Diabetic Patient
		Patient Education and Preventive Practices
		Postoperative Management
		Postoperative Insulin Management
		Summary
		Case Study
		References
	17: Perioperative Care of the Orthopedic Patient with Gastrointestinal and Liver Issues
		Introduction
		Preoperative Evaluation
			Identification of Conditions That Affect Postoperative Gastroenterological Outcome
				Elevated Transaminases Without Cirrhosis
				Cirrhosis and Chronic Liver Disease
			Optimization of Gastroenterological and Hepatic Conditions That May Affect Postoperative Outcome
			The Assessment of Postoperative Risk
			Elevated Liver Function Tests without Cirrhosis
		The Postoperative Period
			Postoperative Nausea and Vomiting
			Postoperative Abdominal Distention
			Clostridium difficile Colitis and Postoperative Diarrhea
			Postoperative Gastrointestinal Bleeding
		Summary
		Case Studies
			Case 1
			Case 2
			Case 3
			Case 4
		References
	18: Perioperative Care of the Orthopedic Patient with Neurological Disease
		Introduction
		The Preoperative Evaluation
		Assessment of Perioperative Risk
			Cerebrovascular Diseases
			Neurodegenerative and Neuromuscular Diseases
			Epileptogenic Disorders
			Cerebral Aneurysms and Arteriovenous Malformations
		Optimization of the Patient with Neurological Disease
			Cerebrovascular Disease
			Epileptogenic Disorders
			Cerebral Aneurysms and Arteriovenous Malformations
			Neurodegenerative and Neuromuscular Diseases
		Postoperative Complications
			Stroke
			Managing Patients with Parkinson Disease in the Hospital Setting
			Peripheral Nerve Injury
			Postoperative Delirium
				Causes
				Presentation
				Evaluation
				Treatment
		Summary
		Case Studies
			Case 1
			Case 2
		References
	19: Perioperative Care of the Orthopedic Patient with Sleep-Disordered Breathing: Obstructive Sleep Apnea
		Introduction
		Obesity Hypoventilation Syndrome
		Perioperative Implications
		Preoperative Evaluation, Risk Assessment, and Clinical Management
		Intraoperative Considerations
			Airway Management Complications
			Medications
				Inhalational Agents and Propofol
				Neuromuscular Blocking Agents
				Opioids
				Benzodiazepines
			Anesthesia Technique
		OSA in the Postoperative Setting
			Patient Extubation
			Patient Positioning
			Patient Monitoring
			Oximetry
			Supplemental Oxygen
			CPAP
			Pain Management
		Healthcare Challenges
		Summary
		Case Report
		References
	20: Perioperative Care of the Patient with Psychiatric Disease
		Introduction
		Preoperative Assessment
			Preoperative Assessment of Psychiatric Medications
			Preoperative Assessment of Substances of Abuse
			Preoperative Assessment of Capacity
			Preoperative Prevention of Delirium
		Postoperative Psychiatric Issues
			Postoperative Delirium
			Postoperative Withdrawal and Intoxication
		Psychiatrically Difficult Patients
		Summary
		Case Studies
			Case 1
			Case 2
		References
	21: Perioperative Care of the Orthopedic Patient with Chronic Pain
		Introduction
		Chronic Pain
			Strategies for Perioperative Pain Control
		Substance Use Disorder
		Mental Health Problems
		Summary
		Case Studies
			Case 1
			Case 2
			Case 3
		References
	22: Perioperative Care of the Orthopedic Patient with Gout
		Introduction
		Gout in the Perioperative Context
		General Principles of Gout Management
		Approach to Preoperative Management of Gout
		Approach to Postoperative Gout Flares
		Using Discharge Planning to Improve Long-Term Gout Management
		Summary
		Case Study
		References
Part IV: Specific Perioperative Problems in Orthopedic Surgery
	23: Perioperative Care of the Elderly Orthopedic Patient
		Introduction
		Age-Related Perioperative Risk Factors
			Cognitive Impairment
			Frailty
			Immobility and Functional Dependency
			Poor Nutrition
			Transitions
		Specific Clinical Problems
			Postoperative Delirium
			Hip Fracture
		Surgical Management
		Postoperative Pain Management in Elderly Patients
		Physical Therapy and Rehabilitation of the Elderly
		Summary
		References
	24: Venous Thromboembolism and Orthopedic Surgery
		Introduction
		Diagnosis of Venous Thromboembolism
			Subsegmental Pulmonary Embolism
			Screening for Venous Thromboembolism in Asymptomatic Patients
		Prevention of Venous Thromboembolism
			Nonpharmacological Approaches
			Inferior Vena Cava Filters
			Pharmacological Options
		Venous Thromboembolism Prophylaxis in Orthopedic Patients
			Hip and Knee Arthroplasty
			Hip Fracture Surgery
			Spine Surgery
			Knee Arthroscopy
			Shoulder Arthroplasty
			Foot and Ankle Procedures
		Conclusions and Summary
		References
	25: Coagulation Disorders and Orthopedic Surgery
		Introduction
		The Preoperative Evaluation
		Hemostasis
		Evaluation and Approach of Primary Hemostasis: Platelet Deficiency
		Evaluation and Approach to Secondary Hemostasis: Clotting Factor Deficiency
		Specific Chronic Diseases
		Summary
		Case Study
		References
	26: Perioperative Nutrition in the Orthopedic Surgical Patient
		Introduction
		Preoperative Nutrition
			Enhanced Recovery after Surgery (ERAS)
		Early Feeding Postoperatively
			Minimizing NPO Status
			Diet Progression
			Adequate Postoperative Nutrition
		Undernutrition and Malnutrition
			Identifying Malnutrition
		Obesity
			Weight Loss Intervention
		Diabetes Mellitus
		Nutrition-Related Complications
			Postoperative Ileus
			Skin Integrity
		Enteral Nutrition Support
		Parenteral Nutrition Support
		Conclusion and Summary
		Case Study
			Inpatient Registered Dietitian Initial Assessment Note
				Assessment
				Diagnosis
				Intervention
				Monitoring and Evaluation
		References
	27: Infection and Perioperative Orthopedic Care
		Introduction
		Preoperative Risk Assessment and Risk Reduction
			Non- modifiable Risk Factors
			Modifiable Risk Factors
				Metabolic Disease
				Diabetes/Hyperglycemia
				Obesity
				Malnutrition
				Smoking
				Inflammatory Arthritis
				Corticosteroids
				Human Immunodeficiency Virus (HIV)
				Chronic Illness
		Preoperative Screening
			Dental
			S. aureus Colonization
			UTI/Bacteriuria
			Infections at Other Sites
			Infection at the Operative Site
			Dermatologic Disease
		Perioperative Management of Infection Risk
			Skin Preparation
			Antibiotic Prophylaxis
		Postoperative Management
			Postoperative Fever
			Postoperative Wound Issues
				Early Postoperative Period
				Surgical Site Infections
		Orthopedic Surgery in the Patient with Known Orthopedic Infection
			Surface Cultures
			Synovial Fluid
			Other Collections
			Wound Cultures
			Blood Cultures
		Late Considerations in Arthroplasty Patients
		Summary
		Case Study
		References
	28: Risks and Benefits of Bilateral Total Knee Replacement Surgery
		Introduction
		Epidemiology and Trends
		Benefits of Single-Stage Bilateral Total Knee Arthroplasty
			Clinical Results of Bilateral Total Knee Arthroplasty
			Number of Anesthetic Sessions
			Surgical Time
			Use of Pain Medication
			Patient Satisfaction
			Cost
		Drawbacks of Single-Stage Bilateral Total Knee Arthroplasty
			Mortality
			Cardiac Complications
			Complications Including Thromboembolism
			Postoperative Confusion
			Potential Increase in Wound Infection Rate
			Use of Allogenic Blood Transfusions
			Use of Tertiary Rehabilitation Centers
		Timing of Surgery for BTKA
		Recommendations for Patient Selection
		Summary
		Case Study
		References
	29: Compartment Syndrome and Orthopedic Surgery: Diagnosis and Management
		Introduction
		Perioperative Considerations
			Acute Assessment
			Anesthetic Considerations
			Sign-Out/Documentation
			Informed Consent/Patient Expectations
		The Spectrum of Compartment Syndrome
		Special Consideration in the Perioperative Patient
		Summary
		Case Studies
			Case 1
			Case 2
		References
	30: Bone Health and Orthopedic Surgery
		Introduction
		Background
		Vitamin D and Orthopedic Procedures
		Total Joint Arthroplasty
		Fracture
			Bisphosphonate Therapy
			Denosumab
			Teriparatide
		Spinal Fusion
		The Clinical Assessment of Bone Health
		Summary
		Case Studies
			Case 1
			Case 2
		References
	31: Perioperative Care of the Complex Spine and Scoliosis Surgery Patient
		Introduction
		Preoperative Evaluation
			Cardiac Risk
			Pulmonary Optimization
			Perioperative Glycemic Management
			Intubation and Airway Considerations
			Preoperative Assessment of Bone Health
			Anterior Thoracic Spine Surgery
			Positioning
		Intraoperative Neurological Evaluation
		Intraoperative Hemodynamic Management
		Postoperative Visual Loss
		Postoperative Ventilation
		Postoperative Orthoses and Mobilization
		Postoperative Pain Management
		Summary
		References
	32: Management of Blood Products in Orthopedic Surgery
		Introduction
		Defining Anemia
		Preoperative Interventions
			Preoperative Optimization
			Preoperative Autologous Blood Donation
			Iron
				Safety
			Erythropoietin
				Safety
		Intraoperative Interventions
			Pharmacologic Antifibrinolytics
				Lysine Analogues: Tranexamic Acid and Epsilon-Aminocaproic Acid
				Tranexamic Acid
					Safety
				Aprotinin
				DDAVP
					Safety
				Recombinant Factor 7
				Fibrin Sealants
			Non-pharmacologic
				Electrocautery
				Hypotensive Anesthesia
					Safety
				Hemodilution
					Safety
				Tourniquet
				Intraoperative/Postoperative Blood Reinfusion
					Safety
		Postoperative Interventions
			Drains
			Transfusion Trigger
		Combination of Techniques/Algorithm
		Summary
		Case Study
		References
Part V: Role of Allied Services
	33: Professional Nursing Practice in the Orthopedic Care Setting
		Introduction
		Magnet Recognition Program
		Patient Assessment
		Care Coordination
		Patient Education
		Preoperative Education
		Postoperative Education
		Follow-Up After Discharge
		Complex Care and Nurse Specialization
		Identification and Management of Postoperative Orthopedic Complications
			Compartment Syndrome
			Thromboembolism
			Nosocomial Surgical Site Infection
		Summary
		References
	34: The Approach to Physical Therapy Following Orthopedic Reconstructive Surgery
		Introduction
		Preoperative Education
		Functional Milestones
		Postoperative Rehabilitation Following Orthopedic Surgery
		Postoperative Rehabilitation Following Total Knee Arthroplasty
		Postoperative Rehabilitation Following Total Hip Arthroplasty
		Rehabilitation Following Spine Surgery
		Summary
		Case Study: Right Total Hip Arthroplasty
		References
	35: Introduction of Clinical Pathways in Orthopedic Surgical Care: The Experience of the Hospital for Special Surgery
		Introduction
		The Key Elements of Clinical Pathways Addressing Total Joint Arthroplasty
			Elements of Pre-Hospital Preparation for Total Joint Replacement
			Perioperative Pain Management
			Post-mobilization and Physical Therapy: Fast-Track Rehabilitation
		Successful Implementation of Clinical Pathways
		Summary
		References
	36: Achieving Value in Orthopedic Surgery: Clinical Pathways, Bundled Payment Programs, and Proactive Risk Assessment for Elective Orthopedic Procedures
		Introduction
		Bundled Payment Models
		Proactive Risk Assessment
			Reasons to Assess Risk
			Surgical Consultation
				Medical Clearance and Risk Optimization
					Obesity and Malnutrition
					Smoking
					Substance Abuse
					Ischemic Heart Disease
					Congestive Heart Failure
					Stroke
					High-Risk Surgery
					Diabetes Mellitus
					Serum Creatinine >2 or Chronic Kidney Disease
			Postsurgical Risk Assessment
				Surgery-Specific Complications
				Operative Time
				Blood Loss
			Pre-Discharge Risk Assessment
			Post-Discharge Risk Assessment
		Summary
		Case Study
		References
	37: Bioethical Considerations in Perioperative Orthopedic Medicine
		Introduction
			Basic Concepts of Bioethics
				Beneficence
				Nonmaleficence
				Justice
				Autonomy
				Professional Duty
				Capacity and Competency
				Vulnerable Populations
		Common Ethical Problems That Arise in the Perioperative Setting
			Informed Consent
			Capacity, Competency, and Advanced Directives
			Clinical Ethics Consultation
		Summary
		Case Study
			Refusal of Care and “Do Not Resuscitate” Orders
			Discussion
		References
Index