Orthopaedic surgery

This chapter discusses the anaesthetic management of orthopaedic surgery. It begins with general principles of the anaesthetic management of orthopaedic surgical patients, including the management of fat embolism syndrome (FES), bone cement implantation syndrome (BCIS), and the use of tourniquets. Surgical procedures covered include total hip joint replacement (THJR) (including revision THJR); femoral neck fracture surgery; total knee joint replacement (TKJR); arthroscopy; cruciate ligament repair; ankle surgery; foot surgery; spinal surgery (including the cervical spine); shoulder surgery (including total shoulder joint replacement (TSJR)); elbow replacement surgery and hand surgery.

1484 Tranexamic Acid Use to Decrease Blood Loss in Primary Shoulder and Elbow Replacement: A Systematic Review and Meta-Analysis

Tranexamic acid (TXA) is an inexpensive, commonly used antifibrinolytic agent that has been shown to significantly reduce perioperative blood loss and transfusion requirements after total hip and knee replacement. We conducted a systematic review and meta-analysis to synthesise the latest evidence regarding the effects of TXA on blood loss in total shoulder replacement (TSR) and total elbow replacement (TER). We systematically searched MEDLINE, EMBASE and CENTRAL from inception to 03 September 2020 for randomised controlled trial (RCTs) and observational studies. Our primary outcome was blood loss, and secondary outcomes included the need for blood transfusion and venous thromboembolic (VTE) complications. Four RCTs and five retrospective cohort studies (RCS) met eligibility criteria for TSRs, but none for TERs. RCT data determined that TXA administration significantly decreased estimated total blood loss, postoperative blood loss, change in haemoglobin (Hb) and total Hb loss when compared to placebo. RCS data demonstrated significant association between TXA administration and decreased in postoperative blood loss, change in Hb, change in Hct and length of stay. This meta-analysis demonstrates that TXA administration in primary TSR significantly decreases blood loss compared with placebo and is associated with lower blood loss and shorter length of stay compared with no treatment with no increase in VTE complications. TXA administration should be part of a wider blood management strategy to minimise perioperative blood loss and blood transfusion requirements in patients undergoing TSR. Further research is needed to demonstrate if a similar treatment benefit exists in patients undergoing TER.

A quantitative analysis of two cementing techniques in total elbow replacement: A cadaveric study

One of the reasons for failure of total elbow replacement is loosening of the ulnar component. Cementing techniques are often outdated. A special small nozzle is needed for the ulnar component, when a cement gun is used. This may not always be available, or surgeons may prefer to use a syringe. We postulated that the use of a cement gun and smaller nozzle would result in improved filling of the ulnar canal. A cadaveric study was performed in which the ulnas of paired specimens were cemented with a cement gun or with a syringe. A 3D printed ulnar component was inserted and computed tomography scanning was performed on all specimens. Filling of the ulnar intramedullary canal was analysed using 3D reconstructions of the specimens. A greater degree of filling was seen by the use of the cement gun in 85.7%. Filling was 52.7% in the syringe group (25.1–78.7%), compared to 63.3% for the cement gun group ( p < 0.05). The use of a small nozzle cement gun provided a significantly higher filling degree of the ulnar canal. We recommend to always use a cement gun with a specific small nozzle to cement the ulnar component in total elbow arthroplasty.

Reconstruction of Elbow Joint and Soft Tissue Defect with Anterolateral Thigh Flap and Total Elbow Replacement: A Case Report

Soft tissue and bone defect due to the machinery penetrating injury of elbow joint are a rare and challenging problem for reconstructive surgeons. After reconstructing soft tissue with anterolateral thigh (ALT) flap and external fixator, the authors planned restoration of elbow function using total elbow replacement (TER). Finally, the patient regained the soft tissue reconstruction and the motion of the elbow using TER, and satisfied with the clinical results. Therefore, the authors present the successful case of ALT flap and TER to treat the machinery penetrating the injury of the elbow.