天美传媒

Orthopedic anesthesia; Arthroscopy; Regional blocks; General anesthesia; Spinal anesthesia; Epidural anesthesia; Nerve blocks; Multimodal analgesia; Ultrasound guidance; Local infiltration analgesia; Postoperative pain management

Introduction

Orthopedic and arthroscopic surgeries constitute a significant proportion of surgical interventions worldwide, addressing conditions like joint degeneration, fractures, ligament injuries, and chronic musculoskeletal disorders. These surgeries range from minimally invasive arthroscopies to major joint replacements and spinal procedures, each requiring tailored anesthetic approaches. The choice of anesthesia is influenced by the type of surgery, duration, patient comorbidities, and anticipated postoperative pain [1].

Historically, general anesthesia was the predominant modality for most orthopedic operations. However, advances in regional techniques have transformed perioperative care, offering improved pain control, fewer systemic side effects, and enhanced recovery. Anesthesiologists now utilize a broad spectrum of techniques, including neuraxial blocks (spinal and epidural), peripheral nerve blocks, and local anesthetic infiltration, often in combination with systemic analgesics and sedatives. This integrative approach aligns with modern goals of anesthesia—maximizing patient safety, minimizing opioid use, and enabling early mobilization [2].

Description

General anesthesia

General anesthesia (GA) induces a reversible state of unconsciousness, analgesia, amnesia, and muscle relaxation. It is frequently used in orthopedic surgeries requiring complete immobility, such as spinal fusion or complex trauma reconstructions. Induction typically involves intravenous agents like propofol or etomidate, followed by maintenance with volatile agents such as sevoflurane or desflurane, and opioid or non-opioid analgesics. GA allows precise control over airway and ventilation, making it suitable for long-duration procedures or patients with respiratory issues. However, it is associated with systemic effects, including cardiovascular depression, postoperative nausea, and increased risk of delirium, especially in elderly patients. These concerns have prompted a shift toward regional anesthesia when feasible [3].

Spinal and epidural anesthesia

Spinal and epidural anesthesia, classified under neuraxial techniques, involve the administration of local anesthetics into or near the spinal cord. Spinal anesthesia is a single-shot technique delivering drugs into the cerebrospinal fluid (CSF), producing rapid and dense anesthesia ideal for lower limb procedures. Common agents include bupivacaine and ropivacaine, often combined with intrathecal opioids for extended analgesia.

Epidural anesthesia, in contrast, involves catheter-based infusion into the epidural space, allowing for titratable anesthesia and postoperative pain control. Though slower in onset, epidurals offer the advantage of continuous dosing, making them suitable for prolonged procedures or labor-intensive joint replacements. Neuraxial anesthesia reduces surgical stress response, lowers thromboembolic risk, and limits systemic opioid exposure. However, complications like hypotension, urinary retention, and rare instances of nerve damage necessitate cautious administration [4].

Peripheral nerve blocks

Peripheral nerve blocks have gained prominence in arthroscopic and joint surgeries. They involve the injection of local anesthetics near specific nerves to block sensory and motor function in a targeted region. Common blocks in orthopedic settings include:

Femoral nerve block: Frequently used in knee arthroscopies and total knee arthroplasties.

Adductor canal block: A motor-sparing alternative to femoral block for postoperative knee analgesia.

Interscalene block: Employed for shoulder and upper limb procedures [5].

Popliteal sciatic block: Applied in ankle, foot, and Achilles tendon surgeries.

Ultrasound guidance has significantly improved the precision and safety of these blocks, reducing complications such as inadvertent vascular puncture or nerve injury. Long-acting anesthetics like ropivacaine ensure effective intraoperative anesthesia and prolonged postoperative analgesia.

Local infiltration analgesia (LIA)

LIA involves the intraoperative injection of a cocktail of local anesthetics, anti-inflammatory drugs, and vasoconstrictors into the surgical field. Widely used in joint arthroplasty, especially knee and hip replacements, LIA provides site-specific analgesia, facilitates early mobilization, and reduces opioid requirements. Its advantages include simplicity, minimal motor blockade, and suitability in patients where neuraxial or nerve blocks are contraindicated. However, its analgesic duration is shorter, and efficacy may vary depending on surgical technique and patient factors [6].

Discussion

Choosing the optimal technique

Selecting the appropriate anesthesia method is a multidimensional process involving:

Patient factors: Age, comorbidities (e.g., cardiac, pulmonary, coagulation disorders), prior anesthesia history, and patient preferences.

Surgical factors: Duration, invasiveness, expected postoperative pain, and the need for intraoperative muscle relaxation or sedation [7].

Postoperative goals: Early ambulation, participation in physiotherapy, and minimal sedation.

In elderly or high-risk patients, regional anesthesia (spinal or nerve blocks) offers superior safety profiles. Arthroscopic surgeries, being minimally invasive, often benefit from peripheral blocks combined with light sedation. For major joint replacements, combined spinal-epidural or nerve blocks with LIA and systemic analgesics form the cornerstone of multimodal analgesia.

Benefits of regional anesthesia

Numerous studies support the benefits of regional techniques in orthopedic settings:

Reduced opioid use: Decreasing opioid-related side effects like nausea, vomiting, and respiratory depression [8].

Improved pain scores: More effective pain control immediately post-surgery.

Shorter hospital stay: Faster functional recovery and patient satisfaction.

Lower complication rates: Decreased incidence of thromboembolism, pulmonary complications, and cognitive dysfunction.

In addition, patient-centric programs like Enhanced Recovery After Surgery (ERAS) increasingly incorporate regional anesthesia and tailored analgesia to optimize perioperative outcomes [9].

Emerging techniques and innovations

Technological advancements have improved the precision and effectiveness of anesthesia techniques:

Ultrasound-guided blocks: Real-time visualization of nerves and surrounding anatomy ensures accurate drug delivery, enhancing block success and reducing complications.

Continuous peripheral nerve catheters: Provide prolonged analgesia for days post-surgery, particularly valuable in outpatient settings [10].

Adjunctive analgesics: Clonidine, dexmedetomidine, or corticosteroids added to local anesthetics can prolong block duration.

Liposomal bupivacaine: Offers sustained analgesia up to 72 hours when used in LIA or peripheral blocks, reducing the need for additional interventions.

Despite these advances, careful monitoring, skilled technique, and individualized planning remain essential to avoid rare but serious complications like local anesthetic systemic toxicity (LAST) or nerve injury.

Conclusion

Anesthesia in orthopedic and arthroscopic surgeries has evolved into a highly specialized field, integrating multiple modalities to achieve optimal patient outcomes. While general anesthesia remains indispensable in certain contexts, the expanding role of regional techniques—spinal, epidural, peripheral nerve blocks, and local infiltration—offers superior pain control, fewer complications, and enhanced recovery. The strategic use of multimodal approaches tailored to patient and surgical needs is now central to perioperative care in orthopedics. As innovations such as ultrasound guidance and long-acting formulations continue to emerge, the anesthesiologist’s role becomes even more pivotal in improving safety, comfort, and satisfaction for orthopedic patients. Continued research, education, and collaboration among surgical and anesthesia teams will further refine these techniques, ensuring that advances in anesthetic science translate into better surgical experiences and long-term outcomes for patients undergoing orthopedic and arthroscopic procedures.