Amy L. Ladd MD
Surgeon
Andrew C. Karich MD
Surgeon
Emilie V. Cheung MD
Surgeon
Lindsey Vokach-Brodsky MB, ChB, FFARCSI
Anesthesiologist
P.936
Arthroscopic Shoulder Surgery
Surgical Considerations
Description: The role of arthroscopy in shoulder surgery has advanced tremendously in the past decade and is now routinely performed by most shoulder surgeons. Arthroscopic procedures include subacromial decompression (SAD), distal clavicle resection (Mumford procedure), debridement (for labral tear, infection, or synovitis), rotator cuff (RC) repair, anterior capsule-labral repair for recurrent dislocation (Bankart repair), capsular plication for multidirectional instability (MDI), capsular release for frozen shoulder, andrepair of SLAP lesions (superior labral anterior-posterior tears).
Procedures done arthroscopically are less painful postoperatively than open procedures, because they produce less trauma to normal tissues. Rehabilitation is, therefore, facilitated. Interscalene block has been shown to provide good postop analgesia of shorter duration, but its clinical application with arthroscopic procedures is surgeon-dependent because the postoperative pain is usually moderate to mild. Some surgeons prefer only a general anesthesia for shoulder arthroscopy. The use of indwelling intra-articular pain catheters has fallen out of favor in the past few years due to multiple case reports of chondrolysis, a devastating complication characterized by end-stage arthrosis of the glenohumeral joint.
Arthroscopic shoulder surgery may be performed in the beach-chair or lateral decubitus position. Beachchair positioners are available with a trough for the head and a breakaway shoulder pad to provide important access to the posterior shoulder. The lateral decubitus position utilizes distal traction of 5–10 lbs, with the arm abducted 30–45°. Both are safe positions for the brachial plexus, because the shoulder is not excessively abducted. The “down” arm in the lateral position is placed in forward flexion, and an axillary roll is placed underneath the upper chest wall.
Initially, an 18-ga spinal needle is inserted into the glenohumeral joint, passing through the posterior deltoid and infraspinatus muscle and the posterior capsule of the joint (see shoulder anatomy, Fig. 10.2-1). Placement is verified by injecting saline to inflate the joint capsule. A stab incision is made using a No. 11 blade in the direction previously defined by the finder needle. Sharp, then blunt trocars are used to gain access to the joint and permit insertion of the arthroscopic device. Improper insertion of the instruments can injure the axillary or suprascapular nerves and the cartilage of the glenohumeral joint. Initial diagnostic arthroscopy is carried out through the posterior portal. Bupivacaine 0.5% with epinephrine 1:200,000 often is infiltrated into portals and the joint or subacromial space at the onset of surgery to help with hemostasis. An anterior portal is used for instrumentation within the glenohumeral joint. After joint arthroscopy, the scope is placed into the subacromial space, where a direct lateral portal is used for instrumentation. Accessory portals are established as needed, depending on the procedure performed. Joint debridement and anterior capsulolabral stabilization are usually performed through anterior portals. RC repair, subacromial bursectomy, acromioplasty, and distal clavicle resection are done within the subacromial space (deep to the deltoid and superficial to the RC). Epinephrine (1 mg/3 L) in the irrigation fluid and maintaining MAP < 80 mmHg help control bleeding, thus enhancing visualization during surgery.
Usual preop diagnosis: Rotator cuff tear; subacromial impingement; glenohumeral instability; AC arthritis; labral tear
Summary of Procedures
|
Position |
Lateral decubitus or beachchair |
|
Incision |
Posterior arthroscopic portal, anterior instrumentation portal, lateral instrumentation portal for visualizing subacromial bursa; superior portal for semisitting position |
|
Special instrumentation |
Arthroscope; power burrs; arthroscopic shavers; suture-passing instruments; bone anchors; radiofrequency cautery |
|
Unique considerations |
Rigid eye patch over ipsilateral eye, to prevent corneal abrasion, suggested. Positioning of the head with appropriate support, removing upper section of operating table, if possible, for better access with semisitting position. ETT taped to opposite side of face. MAP ≥ 80. |
|
Antibiotics |
Cefazolin 1 g iv preop, particularly if bone work performed. |
|
Surgical time |
Positioning the patient is time-intensive; can add as much as 45 min. |
|
EBL |
Minimal: < 200 mL (less with use of epinephrine, electrocautery, and laser) |
|
Postop care |
Frequently outpatient; may be overnight if interscalene or supraclavicular block is given or reconstructive procedure performed. Intraarticular pain catheter commonly used. |
|
Mortality |
Rare |
|
Morbidity |
VAE possible |
|
Pain score |
4 (diagnostic); 5–7 (reconstruction) |
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|
Figure 10.2-1. Anatomy of the shoulder joint, anterior. (Reproduced with permission from Hoppenfeld S, deBoer P, Surgical Exposures in Orthopaedics: The Anatomic Approach, 2nd edition. Lippincott Williams & Wilkins, 1994.) |
P.938
Patient Population Characteristics
|
Age range |
15–40 yr (instability); 35–75 yr (rotator cuff and acromial pathology) |
|
Male:Female |
2:1–4:1 |
|
Incidence |
Very common: > 50,000/yr |
|
Etiology |
Young patients: usually sports-related |
|
Associated conditions |
Cervical arthritis and radiculopathy with rotator cuff pathology |
Anesthetic Considerations
See Anesthetic Considerations following Surgery for Shoulder Instability, p. 944.
Suggested Readings
Surgery for Acromial Impingement, Rotator Cuff Tears, and Acromioclavicular Joint Arthritis
Surgical Considerations
Description: Subacromial impingement is a common degenerative condition of middle age. It may be related to extrinsic anatomic factors (e.g., hooked acromion), a traumatic episode, or intrinsic factors (e.g., tissue degeneration). The subacromial space (space between the acromion and humeral head) is occupied by the supraspinatus (superior rotator cuff [RC]) muscle and tendon and the bursa, which allows for smooth gliding of the cuff tendon under the acromion. Trauma produces hemorrhage and inflammation in the bursa; swelling of the bursa decreases the space available under the acromion. These tissues may then be “pinched” between the greater tuberosity of the humerus and the lateral aspect of the acromion (Fig. 10.2-2) with forward elevation or abduction of the arm. This further increases the inflammation, producing a vicious cycle.
Impingement of the anterolateral acromion on the insertion of the supraspinatus (along with poor vascularity of this part of the cuff) is a leading hypothesis for the etiology of degenerative RC tears.
P.939
|
Figure 10.2-2. Abduction of the arm can impinge the subacromial bursa between the greater tuberosity and the undersurface of the acromion and coracoacromial ligament. (Reproduced with permission from Hoppenfeld S, deBoer P: Surgical Exposures in Orthopaedics: The Anatomic Approach, 2nd edition. Lippincott Williams & Wilkins, 1994.) |
AC joint arthritis is a common radiographic finding in adults, but it is often asymptomatic. Distal clavicle excision is performed for clinically symptomatic AC joint arthritis.
Subacromial impingement: Surgical treatment of subacromial impingement is indicated when nonoperative treatment (e.g., cortisone injection, physical therapy) fails. Surgery involves shaving of the anterolateral aspect of the undersurface of the acromion (creating a flat surface, and providing more room in the subacromial space). This may be accomplished with open techniques in combination with open RC repair, but it is more commonly done arthroscopically. The bursa is usually inflamed and quite vascular. Bleeding may obscure arthroscopic visualization and is controlled with electrocautery, epinephrine in the irrigant, and by maintaining relative ↓ BP (MAP < 80 mmHg).
Rotator cuff tears: RC (Fig. 10.2-3) repair may be performed using the direct lateral open approach, the mini-open (deltoid-splitting) approach in conjunction with arthroscopy, or all arthroscopically. If a deltoid-splitting incision is used, care is taken not to extend the split more than 5 cm distal to the acromion because of possible injury to the axillary nerve, which innervates the deltoid 5 cm or more from the lateral aspect of the acromion. If the beachchair position is used for open RC surgery or arthroscopy, the upper limb is draped free. The arm is manipulated, and traction is frequently applied. It is important that the head is secured (the head may be taped to the table or special beachchair positioner), the eyes are protected, and that the anesthesiologist frequently checks to see that the surgeon is not pulling the patient off the table (not always apparent from the surgeon's side of the drape). Traction on the brachial plexus is more likely in the lateral decubitus position 2° arm traction.
Open RC repair involves suturing the cuff insertion back to the greater tuberosity through drill holes or with suture anchors. Arthroscopic repair requires percutaneous anchor placement and arthroscopic suture-passing and knot-tying. Bleeding is minimal with the arthroscopic technique, but may approach 400 mL with an open procedure. Both require that the patient remain relaxed until all dressings are applied and he/she is fitted with an abduction sling. Patients typically are admitted for 24 h for pain control or if a drain is used.
AC joint disease: Surgery for AC joint arthritis is usually performed in conjunction with SAD and/or RC repair and may be done open or arthroscopically. It involves simple resection of the distal 5 mm of the clavicle through an incision directly over the joint or through an accessory anterior portal. Again, relative ↓ BP is required for the arthroscopic procedure.
Repair of AC joint dislocation (“shoulder separation”) is uncommon. Most AC
P.940
separations are treated nonoperatively, because long-term functional results are the same or better than those treated surgically. Severe AC separations occasionally require surgery, when the dislocated clavicle is buttonholed posteriorly through the trapezius, the deltoid origin has been avulsed from the clavicle, or the clavicle is displaced inferiorly below the cricoid process. Repair is performed in the beachchair position with the incision carried out over the AC joint and distal third of the clavicle. The clavicle is reduced and held in place with a large screw into the base of the coracoid, a large suture wrapped around the coracoid, or with K-wires across the AC joint. The coracoclavicular ligament often is repaired or reconstructed with tendon graft, or the coracoacromial ligament is transferred from the edge of the acromion to the clavicle. Following reduction and fixation, the deltoid is reattached to the clavicle if it has been avulsed, and the patient is placed in an immobilizer after skin closure. The operation is technically challenging and the brachial plexus and subclavian vessels are at risk with screw placement and with inferior dislocations.
|
Figure 10.2-3. Lateral view of the right shoulder showing a rotator cuff repair. Reproduced with permission from Lafosse L, Brozska R, Toussaint B, et al. The outcome and structural integrity of arthroscopic rotator cuff repair with use of the double-row suture anchor technique. J Bone Joint Surg, 2007; 89:1533-41. A: Rotator cuff tear. B: Rotator cuff repair with suture anchors. |
P.941
Usual preop diagnosis: RC tears (partial or complete); AC arthritis; impingement; bursitis; bicipital tendinitis; AC separation
Summary of Procedures
|
Position |
Beachchair; semisitting, ~40–70°; or lateral decubitus |
|
Incision |
Oblique, saber-type incision anteriorly over distal acromion; lateral or deltopectoral incision for wider exposure; deltoid-splitting incision for RC tears |
|
Special instrumentation |
Power equipment for bone work; self-retaining retractors for cuff repairs; suture anchors |
|
Unique considerations |
Rigid eye protection for ipsilateral eye and careful head positioning |
|
Antibiotics |
Cefazolin 1 g iv preop |
|
Surgical time |
1–3 h |
|
Closing considerations |
Muscle relaxation when mobilizing cuff and during closure. Arm in sling and swathe, or abduction pillow for large tears. Immobilizer should be positioned prior to awakening patient to minimize potential for rupture of repair. |
|
EBL |
200–400 mL |
|
Postop care |
Maintenance of position in sling and swathe; no active motion of shoulder girdle for 2 d–6 wk, depending on procedure. |
|
Mortality |
Rare |
|
Morbidity |
Infection: 1–5% |
|
Pain score |
5–8 |
Patient Population Characteristics
|
Age range |
Rotator cuff tears > 40 yr (younger for athletes) |
|
Male:Female |
3:1 |
|
Incidence3,4 |
5–30% of general population affected by RC and acromial conditions, depending on age, thickness of tear, associated conditions |
|
Etiology |
Age-related; trauma (70% involved in light work) |
|
Associated conditions |
Bursitis; tendinitis; impingement; RC disease (especially in first-time glenohumeral dislocations > 40 yr); diabetes and renal failure; hypermobility |
Anesthetic Considerations
See Anesthetic Considerations following Surgery for Shoulder Instability, p. 944.
Suggested Readings
P.942
Surgery for Shoulder Instability
Surgical Considerations
Description: Shoulder instability is classified as multidirectional (MDI)/atraumatic, or unidirectional/traumatic.
MDI is associated with generalized ligamentous laxity (e.g., Ehlers Danlos or Marfan syndromes, or idiopathic), and is treated primarily nonoperatively with physical therapy. Open or arthroscopic capsular shift is performed for recalcitrant cases. This involves “plication” of the capsule and/or labrum to decrease the capsular volume of the shoulder. Patients with MDI, known as “voluntary dislocators,” frequently have psychiatric disorders and are very poor candidates for surgery.
Traumatic instability is usually anterior and is quite common in the young, active population. The shoulder is the most commonly dislocated joint. Recurrent dislocation in young, active patients is common (80–90%) and is associated with avulsion of the capsule/labrum from the anterior-inferior glenoid rim (Bankart lesion). The population undergoing a Bankart repair is almost invariably young and healthy. Older first-time dislocators (age >50 yr) more commonly sustain rotator cuff (RC) tears or fractures, which do not result in chronic instability, but may require operative reduction and RC repair or fracture fixation. Posterior traumatic dislocation is much less common and is associated with high-energy trauma, seizures, or electrocution.
Instability surgery is often preceded by exam under anesthesia and arthroscopic examination, either in the beachchair or lateral decubitus position. The essential feature of instability surgery, whether arthroscopic or open, is the reattachment of the anterior inferior capsulolabral complex back to the rim of the glenoid, thus re-establishing the normal “bumper” effect of the anterior-inferior labrum and decreasing the capsular volume of the shoulder. Nonanatomic procedures (reconstructive) are much less common, but are still performed occasionally. These include transfer of the coracoid process to the anterior glenoid rim (Bristow or Latarjet procedure).
The open Bankart repair is performed in the beachchair position using the deltopectoral approach, with the interval between the deltoid and pectoralis major. The subscapularis (anterior RC muscle) lies just anterior to the joint capsule (Fig. 10.2-4), and this is either detached from its insertion or split. The capsule may then be opened to visualize the joint and rim of the glenoid. The glenoid rim is decorticated, providing bleeding bone to promote healing, and the anterior capsule is reattached through drill holes in the glenoid or with suture anchors. The capsule often is imbricated (overlapping folds) if it is redundant.
The shoulder and deltoid are highly vascular; however, bleeding is usually slight, with careful surgical technique. Major nerves are close but out of the plane of the operative field. The musculocutaneous nerve may be stretched by excessive medial retraction of the coracobrachialis (especially if a coracoid osteotomy is used) and the axillary nerve may be injured if the surgeon strays too far inferiorly.
If a subscapularis-releasing technique is used, the muscle is reattached and must be protected postop. External rotation of the shoulder is prevented for several weeks while the repair heals, and the surgeon prefers that the patient remain anesthetized until a shoulder immobilizer is applied.
The arthroscopic Bankart repair is similar to the open procedure but is performed through two anterior portals with the scope coming in posteriorly. This procedure is less painful postop and allows for more rapid rehabilitation, because the subscapularis is not detached.
P.943
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Figure 10.2-4. Cross section of the joint: The joint capsule is redundant inferiorly to allow abduction. The long head of the biceps tendon traverses the joint. The tendon is surrounded by synovium and, therefore, is anatomically intracapsular but extrasynovial. (Reproduced with permission from Hoppenfeld S, deBoer P: Surgical Exposures in Orthopaedics: The Anatomic Approach, 2nd edition. Lippincott Williams & Wilkins, 1994.) |
Open surgery for posterior dislocation is similar to the open Bankart repair, but it is done in the lateral position and utilizes the interval between the infraspinatus and teres minor. The RC attachment is preserved, but the posterior deltoid is detached and must be protected postop.
Usual preop diagnosis: Recurrent traumatic anterior or posterior instability; MDI; fracture dislocation
Summary of Procedures
|
Open |
Arthroscopic |
|
|
Position |
Beachchair for anterior; lateral decubitus for posterior |
Lateral decubitus or beachchair |
|
Incision |
Deltopectoral (anterior); posterior approach (posterior) |
Multiple small portals |
|
Special instrumentation |
Arthroscopic shaver; suture anchors; glenoid and humeral instrumentation |
⇐ + arthroscopic instruments for suture passing and knot-tying |
|
Antibiotics |
Cefazolin 1 g iv preop if bone work performed. |
⇐ |
|
Surgical time |
2–4 h |
⇐ |
|
Closing considerations |
Continuous anesthesia until application of sling and swathe or abduction pillow |
⇐ |
|
EBL |
200–400 mL |
Minimal |
|
Postop care |
No active motion for 6 wk |
⇐ |
|
Mortality |
Minimal |
⇐ |
|
Morbidity |
Axillary nerve palsy: 15% (may be pre-existing) |
|
|
Pain score |
8 |
5 |
P.944
Patient Population Characteristics
|
Age range |
15–35 yr |
|
Male:Female |
2:1 |
|
Incidence |
Common |
|
Etiology |
Trauma; hypermobility; Sz |
|
Associated conditions |
RC tears (> 50 yr); hypermobility syndrome; Sz disorder; Hill-Sachs lesion (humeral head defect) may require bone grafting; superior labral tears; in most axillary nerve palsies from the injury; iatrogenic (rare) |
Anesthetic Considerations
(Procedures covered: shoulder arthroscopy; surgery for acromial impingement, RC tears, and AC disease; surgery for shoulder dislocations or instability)
Preoperative
Typically, three patient populations present for repair of RC tears or shoulder arthroscopy: (a) healthy post-trauma, (b) nonrheumatoid arthritic, and (c) rheumatoid arthritic. Individuals presenting for repair of shoulder dislocations also may include those with a joint hypermobility syndrome (e.g., Marfan or Ehlers-Danlos) or Sz disorder patients.
|
Respiratory |
Arthritic patients may exhibit Sx of pleural effusion or pulmonary fibrosis. Hoarseness may indicate cricoarytenoid joint (CAJ) involvement → difficult intubation. (See Anesthetic Considerations for Wrist Procedures, p. 914.) Seizure disorder patients who suffer from recurrent shoulder dislocation as a result of frequent grand mal Sz also may suffer from occult aspiration pneumonia or pneumonitis. |
|
Cardiovascular |
Arthritic patients may suffer from chronic pericardial effusions, valvular disease, and cardiac conduction defects. Patients presenting for shoulder stabilization because of joint hypermobility syndromes are likely to have valvular dysfunction and are vulnerable to aortic dissection 2° HTN. These patients may require antibiotic prophylaxis for bacterial endocarditis. |
|
Neurological |
Arthritic patients may have cervical or lumbar radiculopathies that should be documented carefully preop. For example, head flexion may cause cervical cord compression. Patients with severe Sz disorders can suffer from recurrent shoulder dislocations 2° frequent violent grand mal Sz. Such patients should be treated maximally for Sz disorder prior to elective surgery. Be aware that as many as 15% of shoulder dislocations can be accompanied by axillary nerve palsy, which should be documented carefully preop. |
|
Tests: Consider C-spine radiographs to r/o occult subluxations in arthritic patients with neck complaints or upper extremity radiculopathy. Verify therapeutic levels of antiepileptic medication in Sz disorder patients. |
|
|
Musculoskeletal |
Arthritic patients may have limited neck and jaw ROM and may require fiber optic intubation techniques. Bony deformities or muscle contractures may necessitate special attention to positioning. Patients with joint hypermobility syndromes presenting for shoulder surgery also may suffer other joint dislocations 2° positioning problems. |
|
Hematologic |
Virtually all patients will be on some type of anti-inflammatory medication that may result in anemia or Plt inhibition. Ideally, patients should D/C NSAIDs at least 5 d preop; aspirin, 7 d. In addition, selected patients with Ehlers-Danlos are known to have severe coagulation defects that may preclude the use of regional anesthesia. |
|
Endocrine |
Rheumatoid patients may be on oral corticosteroids and may require supplemental perioperative steroids (e.g., 100 mg hydrocortisone q 8 h iv) to treat adrenal suppression, although the routine use of “stress-dose steroids” has been questioned. |
|
Laboratory |
Hb/Hct (in healthy patients); other tests as indicated from H&P. Patients with Ehlers-Danlos syndrome should always have banked blood available for surgery, except for the most trivial of procedures. |
|
Premedication |
Mild-to-moderate premedication (e.g., in adults, midazolam 1–2 mg iv, fentanyl 50–100 mcg iv, titrated to effect) is often desirable before placement of a regional block. |
P.945
Intraoperative
Anesthetic technique: GETA or regional anesthesia (interscalene block), or a combination of the two techniques, can be used. A suprascapular block (when interscalene block is contraindicated) can be used for intraop → postop pain control in arthroscopic shoulder procedures. When logistically feasible, a combined technique is ideal. Unless contraindicated, a long-acting local anesthetic should be used in regional anesthesia for shoulder surgery to ameliorate postop pain.
General anesthesia:
|
Induction |
Standard induction (see p. B-2). Arthritic patients may require awake fiber optic intubation (see p. B-5). |
|
Maintenance |
Standard maintenance (see p. B-2). |
|
Emergence |
Management of emergence and extubation should be routine, except in difficult airway cases which require awake extubation. Patients should remain anesthetized until the shoulder is immobilized. |
Regional anesthesia:
|
Local anesthetics |
2% lidocaine or 1.5% mepivacaine have similar onset times (10–15 min), and similar duration (4–6 h). If extended postop pain control is desired, 0.5% bupivacaine, or 0.5% ropivacaine (each with epinephrine 1:400,000) can be used. Onset is usually within 30 min, with duration up to 10–12 h. Ropivacaine may be preferred for peripheral nerve block due to its decreased cardiotoxicity. |
|
|
Interscalene block |
Anesthetics and doses (epinephrine [2.5–5 mcg/mL]) should be added to local anesthetic whenever possible to decrease peak plasma concentrations: |
|
|
Blood and fluid requirements |
Minimal-to-moderate |
IV catheter placed in contralateral upper extremity. |
|
Monitoring |
Standard monitors (seep. B-1). |
BP cuff should be placed on the arm for beach chair procedures. To help detect VAE, consider precordial Doppler monitoring when semisitting position used. Consider intraarterial BP monitoring for patients with hypermobility disorders because of risk for aortic dissection 2° HTN. |
|
Positioning |
[check mark] and pad pressure points. |
Postural ↓ BP is the most common complication of the semisitting position. Changing to this position gradually can help prevent ↓ BP, as can the use of antiembolism stockings, plus fluid-loading the patient. Marfan and Ehlers-Danlos patients require very gentle positioning to prevent joint dislocations. |
|
Interscalene block complications |
Total spinal |
Resuscitative equipment, including airway management tools, should be immediately available. When possible, nerve blocks should be performed in responsive and cooperative patients to minimize complications. |
|
Other complications |
↓ BP during surgical prep and positioning |
↓ BP during long surgical preps normally can be avoided by using light inhalation anesthesia (e.g., isoflurane 0.3–0.5%) to ensure amnesia, with moderate muscle relaxation to prevent bucking on the ETT, and maintaining adequate hydration. Antiembolism stockings will help prevent venous pooling in lower limbs. |
|
Cardiac dysrhythmia |
Dysrhythmias may be 2° to irrigation fluids containing epinephrine. |
|
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Postoperative
|
Pain management |
PCA (see p. C-3) or regional block techniques. |
Combined regional-general anesthetic techniques are excellent for shoulder procedures, especially with respect to postop pain management. |
|
Tests |
None indicated routinely. |
|
Suggested Readings
P.947
Glenohumeral Shoulder Arthroplasty
Surgical Considerations
Description: Shoulder replacement is performed for pain associated with end-stage arthritis. Primary osteoarthritis (wear-and-tear arthritis) is much less common in the shoulder than in the weight-bearing joints, such as the hip and knee. The most common causes of shoulder arthritis requiring total shoulder arthroplasty (TSA) are osteoarthritis, rheumatoid arthritis; avascular necrosis (AVN); posttraumatic arthritis, and rotator cuff tear arthropathy. Most patients are older than 65 years.
TSA involves replacement of the humeral head with a stemmed prosthesis and resurfacing the glenoid with a polyethylene component. Both components may be cemented or uncemented, depending on the surgeon's preference. Hemiarthroplasty involves only replacement of the humeral side. This is indicated when the humeral head is involved primarily and the glenoid is in good condition, as in severe proximal humerus fractures, AVN of the humeral head, and some chronic dislocators. Replacement of the glenoid is contraindicated in the presence of an unreconstructable massive RC tear because eccentric forces lead to rapid loosening of the glenoid component. Some revision cases require glenoid bone grafting, which increases the complexity and potential blood loss.
Shoulder arthroplasty utilizes the beachchair position and the deltopectoral incision (Fig. 10.2-5). The deltopectoral interval is developed. The subscapularis insertion is incised, and the muscle is reflected medially. The capsule is incised and the joint exposed. The humeral head is dislocated anteriorly, and the head is removed with an oscillating saw. Reamers and broaches are used to prepare the proximal humerus for the prosthesis. If the glenoid is to be resurfaced, it is done before implantation of the final humeral component. The labrum is excised and a motorized reamer is used to remove the cartilage of the glenoid. Glenoid drill holes are made to conform to the back of the prosthesis. The glenoid prosthesis is cemented into place, with the component held in position manually until the cement hardens (~15 min). Trial humeral components are placed, and the appropriate sizing of the head and stem are assessed. The final humeral component is inserted with or without cement. The joint is reduced, and the subscapularis is repaired. Skin closure is followed by placement of a sling or shoulder immobilizer. Postop management includes
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early passive ROM, limiting active internal rotation, and passive external rotation until the subscapularis has healed. Additional limitations may be instituted in revision situations or if RC repair is performed.
|
Figure 10.2-5. Incision in the deltopectoral groove. (Reproduced with permission from Hoppenfeld S, deBoer P: Surgical Exposures in Orthopaedics: The Anatomic Approach,2nd edition. Lippincott Williams & Wilkins, 1994.) |
Usual preop diagnosis: Rheumatoid arthritis; posttraumatic arthritis; AVN; RC arthropathy; 4–part proximal humerus fracture
Summary of Procedures
|
Position |
Semisitting, beachchair |
|
Incision |
Deltopectoral incision (Fig. 10.2-5) or extended incision for complex revision |
|
Special instrumentation |
Glenoid and humeral instrumentation, in addition to usual shoulder instruments; mixing and introduction of cement |
|
Unique considerations |
Systemic illnesses of the patient; systemic complications of use of cement in the patient; precautions in pregnant staff working with methylmethacrylate; usage of laminar flow or UV lighting for total joint precautions, depending on the surgeon's preference and capabilities of the OR. |
|
Antibiotics |
Cefazolin 1 g iv preop, and 48 h postop |
|
Surgical time |
2–5 h |
|
Closing considerations |
Drain; sling and swathe |
|
EBL |
200–1,000 mL |
|
Postop care |
Immediate passive motion. No active internal rotation for 6 wk. |
|
Mortality |
< 1% |
|
Morbidity |
Blood loss |
|
Pain score |
8 |
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Patient Population Characteristics
|
Age range |
45–80 yr |
|
Male:Female |
1:1 |
|
Incidence |
Uncommon |
|
Etiology |
Osteoarthritis; inflammatory arthritis; trauma; avascular necrosis; systemic disease |
|
Associated conditions |
Inflammatory disease; systemic disease; alcoholism; RC pathology; arthritis and radiculopathy; cervical arthritis |
Anesthetic Considerations
Preoperative
Typically, three patient populations present for shoulder arthroplasty: (a) healthy post-trauma, (b) nonrheumatoid arthritic, and (c) rheumatoid arthritic.
|
Respiratory |
Rheumatoid arthritic patients may exhibit Sx of pleural effusion or pulmonary fibrosis. Hoarseness may indicate cricoarytenoid joint (CAJ) involvement → difficult intubation. (See Anesthetic Considerations for Wrist Procedures, p. 914.) |
|
Cardiovascular |
Rheumatoid arthritic patients may suffer from chronic pericardial effusions, valvular disease, and cardiac conduction defects. |
|
Neurological |
Arthritic patients may have cervical or lumbar radiculopathies that should be documented carefully preop. For example, head flexion may cause cervical cord compression. |
|
Musculoskeletal |
Arthritic patients may have limited neck and jaw ROM that may require special intubation techniques. Bony deformities or muscle contracture may necessitate special attention to positioning. |
|
Hematologic |
Virtually all nontrauma patients will be on some type of anti-inflammatory medication that may result in anemia or Plt inhibition. Ideally, patients should D/C NSAIDs at least 5 d preop. |
|
Endocrine |
Rheumatoid patients may be on oral corticosteroids and may require supplemental perioperative steroids (e.g., 100 mg hydrocortisone q 8 h iv) to treat adrenal suppression, although the routine use of “stress-dose steroids” has been questioned. |
|
Laboratory |
Hb/Hct (healthy patients); other tests as indicated from H&P. |
|
Premedication |
Mild-to-moderate premedication (e.g., in adults, midazolam 1–2 mg iv, fentanyl 50–100 mcg iv, titrated to effect) is often desirable before placement of a regional block. |
Intraoperative
Anesthetic technique: GETA or a combination of GETA and regional anesthesia can be used. An interscalene brachial plexus block in combination with GA is excellent for surgical procedures on the shoulder. Unless contraindicated, a long-acting local anesthetic should be used in regional anesthesia for shoulder surgery to ameliorate postop pain.
General anesthesia:
|
Induction |
Standard induction (see p. B-2). Rheumatoid patients may require awake fiber optic intubation (see p. B-5). |
|
Maintenance |
Standard maintenance (see p. B-2). Because of the typically long duration of these cases, the opioid selected as part of the balanced anesthetic technique may be given by continuous infusion (e.g., iv sufentanil [0.25–1.0 mcg/kg/h]). Some surgeons prefer muscle relaxation beyond that provided by volatile anesthetic. The surgeon may request reduction in BP: careful in sitting position to maintain cerebral circulation. |
|
Emergence |
Management of emergence and extubation should be routine except in difficult airway cases that require awake extubation. Emergence from anesthesia should be delayed until patient's shoulder is securely immobilized in the sling and swathe to prevent undesired movement of the newly placed prosthesis. |
P.950
Regional anesthesia:
|
Local anesthetics |
Significant discomfort may be associated with this procedure; therefore, extended postop pain control is desirable. When a single-shot technique is used, 0.5% bupivacaine, or 0.5% ropivacaine (each with epinephrine 1:400,000) can be used. Onset is usually within 30 min, with duration up to 10–12 h. Ropivacaine may be preferred for peripheral nerve block, due to its decreased cardiotoxicity. For continuous catheter techniques, a postop infusion of 6–8 mL/h of 0.2% of any of these agents is appropriate. |
|
|
Interscalene block |
Typical anesthetics and doses. Note that epinephrine [2.5–5 mcg/mL] should be added to the local anesthetic whenever possible to decrease peak plasma concentrations: |
|
|
Blood and fluid requirements |
Moderate-to-significant blood loss |
RBC recovery and reinfusion techniques (e.g., Cell Saver) are advisable because blood loss can be considerable. IV in nonoperative upper extremity. |
|
Monitoring |
Standard monitors (see p. B-1). |
Consider invasive, hemodynamic monitoring in the debilitated or elderly patient. |
|
Positioning |
[check mark]and pad pressure points. |
Postural ↓ BP is the most common complication of the semisitting position. Changing patient to this position gradually can help prevent ↓ BP, as can the use of antiembolism stockings and fluid-loading the patient. Care with neck positioning. Check head position intraoperatively as shoulder traction may lead to injury. |
|
Interscalene block complications |
Total spinal |
Resuscitative equipment, including airway management tools, should be immediately available. |
|
Phrenic nerve block |
|
|
|
Other complications |
Potential for embolic event |
Because of the increased risk of VAE during shoulder arthroplasty, N2O may be D/C'd during placement of humeral component. Use of methylmethacrylate cement has been associated with the sudden onset of ↓ BP and even cardiac arrest, presumably due to profound vasodilation ± associated VAE. ↓ BP during long surgical prep usually can be avoided by using light inhalation anesthesia (isoflurane 0.3–0.5%) to ensure amnesia, with moderate muscle relaxation to prevent bucking on ETT, and maintaining adequate hydration. |
P.951
Postoperative
|
Pain management |
PCA (see p. C-3) or regional block/catheter |
Combined regional-general anesthetic techniques are excellent for shoulder procedures, especially for postop pain management. |
|
Tests |
None indicated routinely. |
Suggested Readings
P.952
Shoulder Girdle Procedures
Surgical Considerations
Description: Trauma about the shoulder girdle in young patients ranges from athletic injuries to life-threatening trauma. Some of these injuries include common athletic injuries, such as acromioclavicular joint separations, which rarely require surgery unless there are associated acromial or clavicular fractures. Posterior sternoclavicular dislocations may warrant surgical stabilization if the trachea is compressed. Clavicle fractures, frequently associated with scapular fractures, occasionally require open reduction.
Scapular fractures involving the glenoid also may require surgical stabilization. Extreme fractures involving the shoulder girdle (scapulothoracic dissociations) include scapular fracture, clavicle fracture, subclavian or axillary artery disruption, and brachial plexus injury. These may coexist with proximal humerus fractures, rib fractures, and pneumothorax. In the older, debilitated patient, the most common injury is proximal humeral fracture, which may be amenable to surgical stabilization or may be so comminuted as to warrant hemiarthroplasty.
A displaced proximal humerus fracture may require open reduction internal fixation with a plate and screws or hemiarthroplasty through a deltopectoral approach utilizing a beachchair position (see Surgery for Shoulder Instability, p. 942, and Glenohumeral Shoulder Arthroplasty, p. 947). A displaced clavicle fracture may require open reduction internal fixation with a plate and screws utilizing a beachchair or supine position. A scapular body fracture would be stabilized with a plate and screws via a posterior approach utilizing a prone or lateral position (see Surgery for Shoulder Instability, p. 942). As with other shoulder procedures, relaxation is necessary upon awakening the patient after the shoulder is placed into an immobilization device.
Usual preop diagnosis: Trauma about the shoulder girdle
Summary of Procedures
|
Anterior |
Posterior |
|
|
Position |
Semisitting or prone |
Lateral decubitus (scapula) |
|
Incision |
Anterior, superior, or oblique for acromioclavicular; supraclavicular for clavicle; deltopectoral for proximal humerus and glenoid |
Posterior lateral border or medial border of scapula, spinous scapula, depending on location |
|
Special instrumentation |
Plates and screws; tension band wiring; proximal humerus replacement for comminuted fractures |
⇐ |
|
Unique considerations |
Multiple traumas warrant early stabilization; may require vascular repair and brachial plexus exploration. |
⇐ |
|
Antibiotics |
Cefazolin 1 g iv |
⇐ |
|
Surgical time |
2–10 h |
⇐ |
|
Closing considerations |
Fracture-dependent; most commonly requires application of sling and swathe. |
⇐ |
|
EBL |
200–1,200 mL or greater, depending on trauma |
⇐ |
|
Postop care |
May require ICU for multiple-trauma patients; otherwise, early mobilization with physical therapy |
⇐ |
|
Mortality |
Mortality dependent on associated conditions: |
⇐ |
|
Morbidity |
Nerve injury (axillary, brachial plexus) |
Axillary and suprascapular⇐ |
|
Pain score |
6–10 |
6 (clavicle and AC joint) |
P.953
Patient Population Characteristics
|
Age range |
15–80 yr, depending on nature of trauma |
|
Male:Female |
5:1 |
|
Incidence |
Common |
|
Etiology |
Trauma |
|
Associated conditions |
Axillary nerve palsy; musculocutaneous nerve palsy; brachial plexus injury; arterial disruption in high-energy trauma; brachial and great vessel injuries and posterior sternoclavicular dislocation pneumothorax |
Anesthetic Considerations
See Anesthetic Considerations following Brachial Plexus Surgery, p. 955.
Suggested Readings
Brachial Plexus Surgery
Surgical Considerations
Description: Brachial plexus injuries occur most commonly in two groups: traumatic birth injuries and high-energy trauma. Surgery ranges from exploration with neurolysis, to repairs, to cable nerve grafting. Typically, the latter requires grafting with the sural nerve, and nerve pedicle transfer, such as transfer of the spinal accessory nerve to denervated paralyzed muscle, combined with muscle transfers. C5-C6 is most commonly injured in obstetrical (Erb's) palsy. Injuries in adults are more commonly closed-traction. Similar to obstetrical palsy, they occur with an outstretched, abducted arm with the neck rotated in the opposite direction. The most severe form includes complete avulsion at the preganglionic level, presenting with a Horner's syndrome, winging of the scapula, and a flail arm.
P.954
These are typically “supraclavicular” injuries, and have a poorer prognosis. Surgical exposure may proceed above the clavicle similar to an anterior neck dissection, or may require an extension below the clavicle. Occasionally, an osteotomy of the clavicle for extensive dissection is required. For axillary nerve dissection, a posterior approach also is used. Open injuries, such as gunshot or knife wounds, are typically “infraclavicular” and have a better prognosis. (See diagram of brachial plexus, Fig. 10.2-6.)
|
Figure 10.2-6. Brachial plexus: Its division into supraclavicular and infraclavicular portions is apparent. The proximal origin of the dorsal scapular nerve and the long thoracic nerve are demonstrated. The T1 spinal nerve arises below the head of the 1st rib. The relation of the cords of the plexus to the axillary artery at the level of the coracoid process (origin of the pectoralis minor and coracobrachialis muscles) is illustrated. The posterior cord and the radial nerve behind the axillary artery are stippled for clarity. (Reproduced with permission from Tindall GT, Cooper PR, Barrow DL: The Practice of Neurosurgery, Vol III. Williams & Wilkins, Baltimore, 1996.) |
Usual preop diagnosis: Obstetrical palsy; adult trauma—most commonly motorcycle accident
Summary of Procedures
|
Position |
Lateral decubitus or semisitting |
|
Incision |
Supra- or infraclavicular, extensile to include deltopectoral incision. Clavicle osteotomy incision will provide for improved exposure. Supraclavicular incision used for supraclavicular brachial plexus. |
|
Special instrumentation |
Nerve stimulator |
|
Unique considerations |
Associated trauma |
|
Antibiotics |
Cefazolin 1 g iv preop |
|
Surgical time |
4–10 h |
|
Closing considerations |
Other incisions if nerve grafts obtained. |
|
EBL |
400–2,000 mL |
|
Mortality |
Minimal |
|
Morbidity |
Bleeding |
|
Pain score |
8 |
P.955
Patient Population Characteristics
|
Age range |
Infants and children: 3 mo–8 yr; adults: 20–40 yr |
|
Male:Female |
Adult: 5:1 |
|
Incidence |
Infants: 0.3–8/1,000 births; adults: commonly associated with motorcycle accidents |
|
Etiology |
Obstetrical palsy; trauma |
|
Associated conditions |
None known |
Anesthetic Considerations
(Procedures covered: shoulder girdle procedures; brachial plexus surgery)
Preoperative
With the exception of traumatic birth injuries, most of these patients are healthy males who have suffered major blunt or penetrating trauma. For the acute and subacute trauma victim, the major anesthesia-related concerns center on associated traumatic injuries. Many adult trauma victims with brachial plexus injuries will be operated on in the first few days after their injury. For infants (usually operated on at 6–12 mo), the major anesthesia-related concerns are those routinely associated with pediatric anesthesia (see Pediatric Orthopedic Surgery, p. 1354.). Approximately half of all trauma victims are intoxicated. The anesthesia-related implications of ethanol intoxication include: decreased anesthetic requirements, diuresis, vasodilation, and hypothermia.
|
Respiratory |
As suggested by coexisting disease or acute trauma injuries. Look for evidence of occult chest injury, including pneumothorax (tachypnea, wheezing, ↓ BP, ↓ PaO2, CXR changes) and pulmonary contusion (multiple rib fracture, ↓ PaO2). |
|
Cardiovascular |
As suggested by coexisting disease or acute trauma injuries. Look for evidence of occult cardiac or mediastinal injuries, such as myocardial contusion (e.g., ECG abnormalities typically consistent with ischemia) or great vessel rupture (e.g., widened mediastinum). |
|
Neurological |
Victims of shoulder trauma are vulnerable to brachial plexus damage. Look for evidence of upper extremity nerve dysfunction and document any injuries preop. The possibility of closed-head injury also should be considered. |
|
Tests: Head CT prior to beginning a procedure under GA in a patient with evidence of head trauma. |
|
|
Musculoskeletal |
As suggested by coexisting disease or acute trauma injuries. The amount of force necessary to produce a brachial plexus injury mandates a C-spine series to r/o C-spine fracture in all victims of brachial plexus trauma. |
|
Laboratory |
In general, most victims of significant trauma are best served by obtaining a wide variety of baseline lab studies to screen for unrecognized injury. These studies generally should include: Hct; CBC; ABGs; UA; renal function tests; LFTs; serum amylase. |
|
Premedication |
None |
P.956
Intraoperative
Anesthetic technique: GETA is preferred over regional techniques because of the unpredictable and prolonged length of these procedures and the need to evaluate brachial plexus function postop.
|
Induction |
Rapid-sequence induction (see p. B-4) is mandatory in unscheduled cases, unless awake fiber optic intubation is performed (see Anesthetic Considerations for Thoracolumbar Neurosurgical Procedures, p. 122). C-spine fracture patients or those with facial injuries may require awake fiber optic intubation (see p. B-5) or other special airway techniques, as indicated from H&P. Hemodynamically unstable, acute-trauma patients can be induced more safely with etomidate (0.3–0.4 mg/kg iv) or ketamine (1–3 mg/kg iv). |
|
|
Maintenance |
Balanced anesthesia with low-dose isoflurane (0.4–0.6%), iv sufentanil (0.25–1.0 mcg/kg/h), and N2O in O2 is suitable for stable patients. Hemodynamically unstable, acute-trauma victims undergoing emergency surgery are not likely to tolerate this regimen and are better served by using a combination of medications designed to have minimal hemodynamic consequences (e.g., fentanyl for analgesia, vecuronium for muscle relaxation, and scopolamine or midazolam for amnesia). N2O is best avoided in the trauma patient. For brachial plexus surgery, some surgeons prefer minimal muscle relaxation after tracheal intubation so that a nerve stimulator can be used to help identify surgical anatomy. |
|
|
Emergence |
Management of emergence and extubation should be routine except in difficult airway or full-stomach cases, which require that extubation be delayed until the patient's airway reflexes have returned and the patient is fully awake. |
|
|
Blood and fluid requirements |
Significant blood loss |
IV catheter placed in the nonoperative upper extremity is usually adequate in hemodynamically stable patients. Unstable, acute-trauma victims require a minimum of 2 large-bore iv catheters or large-bore central lines. |
|
Monitoring |
Standard monitors (see p. B-1). |
Invasive hemodynamic monitoring and TEE should be considered in acute, multiple-trauma victims. Some surgeons request SSEP to make continuous assessment of preop intact brachial plexus possible. When using SSEP monitoring, high doses of volatile anesthetic agents should be avoided because they adversely affect SSEP readings. |
|
Positioning |
[check mark]and pad pressure points. |
Postural ↓ BP is the most common complication of the semisitting position, particularly during the surgical prep period. SCD or antiembolism stockings may be beneficial. VAE is a potential complication of this position. |
|
Complications |
Hemodynamic instability |
Previously unrecognized injuries (e.g., pneumothorax, cardiac tamponade, intracranial bleeding) should be considered as a cause of unexplained intraop hemodynamic instability in all acute-trauma victims. |
|
Possible VAE |
VAE risk is increased with patient in semisitting position. |
|
P.957
Postoperative
|
Complications |
Sepsis |
Many trauma victims survive the initial insult only to die later of sepsis or ARDS. |
|
Pain management |
PCA (see p. C-3). |
|
|
Tests |
Based on concurrent injuries. |
Suggested Readings
Arm Surgery
Surgical Considerations
Description: Surgical procedures on the arm are primarily for trauma or tumor surgery. Other procedures include extended approaches from the shoulder for significant trauma or tendon transfer. Exploration of peripheral nerves, most commonly of the radial nerve, are also included in this category, as are distal extensile approaches from the elbow for trauma or for lateral epicondylitis (“tennis elbow”). Depending on the lesion or fracture, the incision is developed through an internervous or intramuscular compartment. Procedures includeexcisional biopsy for soft tissue or bone tumors of the arm; tumor excision, which may be marginal, wide, or radical, depending on the tumor encountered; tendon transfers, such as pectoralis transfer to replace biceps function, used primarily for brachial plexus injuries; and fractures and nonunion fractures of the humerus. Positioning and location of incision is dependent on the level of the pathology. For example, for fractures involving the proximal half of the humerus, the standard deltopectoral incision may be extended distally along the interval between the biceps and triceps on the lateral aspect of the arm. This approach requires a beachchair (Figure 10.2-7) or, occasionally, supine position. Distal-third fractures are best approached posteriorly with the triceps-splitting approach. Distal fractures that extend into the elbow joint often require an olecranon osteotomy to visualize the fractured joint surface. Posterior approaches to the distal humerus are performed in either the lateral or prone position.
Usual preop diagnosis: Trauma; tumor
Summary of Procedures
|
Position |
Supine; semisitting position for extended deltopectoral; lateral decubitus or prone for distal humerus fractures |
|
Incision |
Anterolateral approach; posterior approach in the lateral decubitus or prone position |
|
Special istrumentation |
Plate and screws; external fixators; intramedullary rods; occasionally, methylmethacrylate cement for tumor surgery; sterile tourniquet for distal humerus; I.I. for fracture surgery |
|
Unique considerations |
CT-guided sclerotherapy preop for vascular tumors; longitudinal incisions for biopsy and tumor excisions (not violating fascial planes) |
|
Antibiotics |
Cefazolin 1 g iv preop |
|
Surgical time |
45 min–6 h |
|
Closing considerations |
Drain frequently required. |
|
EBL |
Minimal—500+ mL, depending on pathology |
|
Mortality |
Varies with pathology |
|
Morbidity |
Bleeding |
|
Pain score |
4–9 |
P.958
Patient Population Characteristics
|
Age range |
Varies with procedure |
|
|
Male:Female |
Varies with procedure |
|
|
Incidence |
Procedure-dependent |
|
|
Etiology |
Fractures; nerve entrapment (radial) following trauma; tumors |
|
|
Associated conditions |
Radial or ulnar nerve injury with humeral fractures |
|
|
Figure 10.2-7. Beachchair positioning for shoulder surgery. Image intensification may be needed for intraoperative radiography (e.g., fracture surgery). (Reproduced by permission from Robinson CM, Page RS. Severely impacted proximal humerus fractures. J Bone Joint Surg 2004; 86:143-55.) |
||
P.959
Anesthetic Considerations
Preoperative
Patients presenting for arm procedures are relatively young and otherwise healthy. Most of these patients present for elective repair of a traumatic injury. The preop workup is appropriate to patient's medical history. Some arm procedures, such as repair of a compound fracture, require immediate attention and necessitate emergency surgery and full-stomach considerations (p. B-4).
|
Laboratory |
Hb/Hct (healthy patients); other tests as indicated from H&P. |
|
Premedication |
Mild-to-moderate premedication (e.g., in adults, midazolam 1–2 mg iv, fentanyl 50–100 mcg iv, titrated to effect) is often desirable before placement of a regional block. |
Intraoperative
Anesthetic technique: GA or regional anesthesia, or a combination of the two, can be used for surgical procedures on the arm. A brachial plexus block via the supraclavicular, infraclavicular or axillary approach is excellent for procedures on the distal arm. The interscalene approach to the brachial plexus is suitable for more proximal humerus procedures. Regional anesthesia alone is a means of avoiding the risk of aspiration pneumonitis associated with GA in the patient with a full stomach. Procedures longer than 3 h usually require general anesthesia in addition to regional. Regional anesthesia with sedation is usually well tolerated in shorter procedures.
General anesthesia:
|
Induction |
Standard induction (see p. B-2) except in acute-trauma patients, where rapid-sequence induction is appropriate (see p. B-4). |
|
Maintenance |
Standard maintenance (see p. B-2). |
|
Emergence |
Management of emergence and extubation should be routine, except in difficult airway cases, which require awake extubation. Skin closure is frequently followed by application of a splint; patient should remain anesthetized during splinting procedure. |
Regional anesthesia:
|
Local anesthetics |
2% lidocaine or 1.5% mepivacaine have similar onset times (10–15 min), and similar duration (4–6 h). If extended postop pain control is desired, 0.5% bupivacaine, or ropivacaine (each with epinephrine 1:400,000) can be used. Onset is usually within 30 min, with duration up to 10–12 h. Ropivacaine may be preferred for peripheral nerve block due to its decreased cardiotoxicity. |
|
Brachial plexus block |
Supraclavicular, infraclavicular and axillary approaches are all suitable. Supraclavicular or infraclavicular blocks are better tolerated in fracture patients, because the arm need not be moved. Ultrasound guidance can improve speed and comfort during block placement. A peripheral nerve catheter may be placed to prolong pain relief in appropriate patients. |