Get an inside look at how Campbell's Operative Orthopaedics approaches perioperative patient care — from anticoagulation management and infection prevention to tourniquet use, blood loss control, and bone grafting techniques.
The gold standard reference for worldwide orthopaedic practice Order your copy today at elsevierhealth.com/9780443117633 From Campbell’s Operative Orthopaedics, 4-Volume Set, 15th Edition Exclusive preview: Perioperative Patient Optimization and Overview of Tendon-to-bone Fixation and Bone Grafting PART I GENERAL PRINCIPLES 138 depends on the age of the patient, the blood pressure, and the size of the extremity. Reid et al. used pneumatic tourniquet pressures determined by the pressure required to obliterate the peripheral pulse (limb occlusion pressure) using a Doppler stethoscope; they then added 50 to 75 mm Hg to allow for col- lateral circulation and blood pressure changes. Tourniquet pressures of 135 to 255 mm Hg for the upper extremity and 175 to 305 mm Hg for the lower extremity were satisfactory for maintaining hemostasis. Wide tourniquet cuffs are more effective at lower infla- tion pressures than are narrow ones. Curved tourniquets on conical extremities require significantly lower arterial oc- clusion pressures than straight (rectangular) tourniquets (Fig. 2.1 ) . The use of straight tourniquets on conical thighs should be avoided, especially in extremely muscular or obese individuals. TOURNIQUET SAFETY Any solution applied to skin must not be allowed to run be- neath the tourniquet, or a chemical burn may result. A cir- cumferential adhesive-backed plastic drape applied to the skin just distal to the tourniquet prevents solutions from running under the tourniquet. Sterile pneumatic tourniquets are avail- able for operations around the elbow and knee. The limb may be prepared and draped before the tourniquet is applied. Rarely, a superficial slough of the skin may occur at the upper margin of the tourniquet in the region of the gluteal fold. This slough usually occurs in obese individuals and is probably related to the use of a straight, instead of a curved, tourniquet. PNEUMATIC TOURNIQUETS Pneumatic tourniquets should be kept in good repair, and all valves and gauges must be checked routinely. The inner tube should be completely enclosed in a casing to prevent the tube from ballooning through an opening, allowing the pressure to fall or causing a “blowout.” The cuff also should be inspected carefully. Single-use sterile disposable tourniquets are preferable because reusable tourniquets must be thoroughly decontami- nated after each use to prevent microbial colonization. Any aneroid gauge must be calibrated frequently. Newer gauges carry instruction cards with them. They are sold with test gauges so that the gauges on the tourniquets can be tested for proper calibration. Many automatic tourniquet control units will self-test when turned on. If there is a dis- crepancy, the unit must be manually checked with a test gauge. If the discrepancy is more than 20 mm Hg, the unit should be repaired or replaced. One of the greatest dangers in the use of a tourniquet is an improperly registering gauge; gauges have been found to be 300 mm off calibration. In ORGANIZATION/STUDY PRESSURE DURATION (MIN) REPERFUSION INTERVAL Association of Surgical Technologists Upper extremity, 50 mm Hg above SBP; lower extremity, 100 mm Hg above SBP Upper extremity, 60; lower extremity, 90 15 min Association of Perioperative Registered Nurses 40 mm Hg above LOP for LOP 130 mm Hg; 60 mm Hg above LOP for LOP 131–190 mm Hg; 80 mm Hg above LOP for LOP 190 mm Hg Upper extremity, 60; lower extremity, 90 15 min deflation after every 1 h of tourniquet time Wakai et al. General recommendation, 50–75 mm Hg above LOP; upper extremity, 50–75 mm Hg above SBP; lower extremity, 90–150 mm Hg above SBP 120 30 min at 2-h point in surgery lasting 3 h Kam et al. 50–150 mm Hg above SBP, using the lower end of the range for the upper extremity and the higher end for the lower extremity 120 10 min at the 2-h point for surgery lasting 2 h Noordin et al. Use LOP; no margin specified 120 NR TABLE 2.5 Published Recommendations on Tourniquet Use From Fitzgibbons PG, DiGiovanni C, Hares S, Akelman E: Safe tourniquet use: A review of the literature, J Am Acad Orthop Surg 20:310, 2012. LOP, Limb occlusion pressure; NR, no recommendation; SBP, systolic blood pressure. Cylinder A B Straight cuff Cone Curved cuff FIGURE 2.1 A, Straight (rectangular) tourniquets fit opti- mally on cylindrical limbs. B, Curved tourniquets best fit conical limbs. (From Pedowitz RA, Gershuni DH, Botte MJ, et al.: The use of lower tourniquet inflation pressures in extremity surgery facilitated by curved and wide tourniquets and integrated cuff inflation system, Clin Orthop Relat Res 287:237, 1993.) 139 CHAPTER 2 PERIOPERATIVE PATIENT OPTIMIZATION AND OVERVIEW OF TENDON-TO-BONE FIXATION AND BONE GRAFTING many tourniquet injuries, the gauges were later checked and found to be grossly inaccurate, allowing excessive pressure. Pneumatic tourniquets usually are applied to the upper arm and thigh, and a well-padded proximal calf tourniquet is safe for foot and ankle surgery. General guidelines for the safe use of pneumatic tourniquets are outlined in Table 2.6 . ESMARCH TOURNIQUETS The Esmarch tourniquet is still in use in some areas and is the safest and most practical of the elastic tourniquets. It is never used except in the middle and upper thirds of the thigh. This tourniquet has a definite, although limited, use in that it can be applied higher on the thigh than can the pneumatic tour- niquet. The Esmarch tourniquet is applied in layers, one on top of the other; a wide band produces less tissue damage than does a narrow one. MARTIN RUBBER SHEETS A Martin rubber sheet bandage can be safely used as a tourni- quet for short procedures on the foot. The leg is elevated and exsanguinated by wrapping the rubber bandage up over the malleoli of the ankle and securing it with a clamp. The distal portion of the bandage is released to expose the operative area. DIGITAL TOURNIQUETS Special attention should be given when using tourniquets on fingers and toes. NOTE! A rubber ring tourniquet or a tourni- quet made from a glove finger that is rolled onto the digit should not be used because it can be inadvertently left in place under a dressing, resulting in catastrophic loss of the digit. A glove finger or Penrose drain can be looped around the proximal portion of the digit, stretched, and secured with a hemostat. It is difficult to include a hemostat inadvertently in a digital dressing. A modified glove finger with a volar flap will help prevent inadvertently leaving the tourniquet in place after surgery (Fig. 2.2 ) . Commercial digital tourniquets (Fig. 2.3 ) with long tails and bright colors help prevent accidental incorporation of the tourniquet into a dressing. Sterile disposable rubber ring tourniquets are now available for use on the upper and lower extremities. These tourniquets are wrapped in stockinette and are applied by rolling the rubber ring and stockinette up the extremity, which exsanguinates the extremity. The stock- inette is then cut away at the operative site. Rubber ring tourniquets are not indicated in the presence of malignancy, infections, significant skin lesions, unstable fractures or dis- locations, poor peripheral blood flow, edema, or deep ve- nous thrombosis. Sizing of these tourniquets is based on systolic blood pressure. PREOPERATIVE ANTIBIOTICS AND TOURNIQUET USE The use of preoperative prophylactic antibiotics in orthopaedic operations has been accepted practice for over 30 years and decreases the likelihood of postoperative infection. Most be- lieve that these antibiotics should be given prior to inflation of the tourniquet to ensure that the antibiotic is present in the tissues before the incision is made. There has been no consensus as to the interval between antibiotic administration and tourni- quet inflation, with variations in time from 5 to 20 minutes being reported. Our institution recommends administration of cefazolin within 1 hour of tourniquet inflation. Studies have shown that a 1-minute interval resulted in cefazolin concentra- tion in soft tissue and bone at or greater than the minimum inhibitory concentrations for microorganisms encountered in Application Apply only to a healthy limb or with caution to an unhealthy limb Size of tourniquet Arm, 10 cm; leg, 15 cm or wider in large legs Site of application Upper arm; mid/upper thigh ideally Padding At least two layers of orthopaedic felt Skin preparation Occlude to prevent soaking of wool Use 50–100 mm Hg above systolic for the arm; double systolic for the thigh; or arm 200–250 mm Hg, leg 250–350 mm Hg (large cuffs are recommended for larger limbs instead of increasing pressure) Time Absolute maximum 3 h (recovers in 5–7 days) generally not to exceed 2 h Temperature Avoid heating (e.g., hot lights), cool if feasible, and keep tissues moist Documentation Duration and pressure at least weekly calibration and against mercury manom- eter or test maintenance gauge; mainte- nance every 3 months TABLE 2.6 Braithwaite and Klenerman’s Modification of Bruner’s Ten Rules of Pneumatic Tourniquet Use Modified from Kutty S, McElwain JP: Padding under tourniquets in tourniquet controlled surgery: Bruner’s ten rules revisited, Injury 33:75, 2002. A B FIGURE 2.2 A, Cut 1 cm from end of corresponding glove finger, then cut through palm half of glove finger at base and extend both ends of cut longitudinally along backside of glove. Remove remaining glove and finger and apply it to palm side of hand. B, Roll glove finger back to serve as tourniquet. Tourni- quet start time can be written on glove flap. (From Osanai T, Ogino T: Modified digital tourniquet designed to prevent the tourniquet from inadvertently being left in place after the end of the surgery, J Orthop Trauma 24:387, 2010.) 141 CHAPTER 2 PERIOPERATIVE PATIENT OPTIMIZATION AND OVERVIEW OF TENDON-TO-BONE FIXATION AND BONE GRAFTING age of the patient and the vascular supply of the extremity, but we recommend leaving the tourniquet inflated for no more than 2 hours. If an operation on the lower extremity takes longer than 2 hours, it is better to finish it as rapidly as possible than to deflate the tourniquet for 10 minutes and then reinflate it. It has been found that 40 minutes is required for the tissues to return to normal after prolonged use of a tourniquet. Consequently, the previous practice of deflating the tourniquet for 10 minutes seems to be inadequate. POST-TOURNIQUET SYNDROME Post-tourniquet syndrome, as first recognized by Bunnell, is a common reaction to prolonged ischemia and is character- ized by edema, pallor, joint stiffness, motor weakness, and subjective numbness. This complication is thought to be re- lated to the duration of ischemia and not to the mechanical effect of the tourniquet. Post-tourniquet syndrome interferes with early motion and results in increased requirement for narcotics. Spontaneous resolution usually occurs within 1 week. ISCHEMIC COMPLICATIONS Compartment syndrome, rhabdomyolysis, and pulmonary emboli are rare complications of tourniquet use. Rasmussen et al. found that muscle beneath the tourniquet had a greater ischemic response than muscle distal to the tourniquet. One study, using transesophageal echocardiography during ar- throscopic knee surgery, showed that asymptomatic pulmo- nary embolism can occur within 1 minute after tourniquet release. The number of small emboli depended on the dura- tion of tourniquet inflation. Vascular complications can oc- cur in patients with severe arteriosclerosis or prosthetic grafts. A tourniquet should not be applied over a prosthetic vascular graft. BLOOD LOSS CONTROL DURING SURGERY When a tourniquet cannot be used because of the location of the surgical site or when blood loss is expected to be high after tourniquet release, routine blood loss control measures should be readily available. These include electrocautery, gel foam, thrombin, and epinephrine. Preoperative planning for larger procedures should include expected blood loss, and preparation should be made to have donor or autologous blood, or both, available and a blood recycling system (cell- saver) present if needed. The use of the fibrinolytic tranexamic acid (TXA) has become popular in large joint arthroplasty surgery for re- ducing blood loss. Luo et al. performed a prospective, ran- domized, double-blind, controlled study that showed equal efficacy in reducing blood loss in primary total hip surgery when TXA was used orally, topically, or by intravenous infu- sion. TXA was administered 2 g orally 2 hours before sur- gery, 2 g into the wound, or 20 mg/kg intravenously. RADIOGRAPHS IN THE OPERATING ROOM Often it is necessary to obtain radiographs during an ortho- paedic procedure. Radiography technicians who work in the operating room must wear the same clothing and masks as the circulating personnel. These technicians must have a clear understanding of aseptic surgical technique and draping to avoid contaminating the drapes in the operative field. Porta- ble radiograph units used in the operating room should be cleaned regularly and ideally are not used in any other area of the hospital. When an unsterile radiograph cassette is to be intro- duced into the sterile field, it should be placed inside a sterile double pillowcase or sterile plastic bag that is folded over so that the exterior remains sterile. The pillowcase or plastic bag is covered by a large sterile towel, ensuring at least two layers of sterile drapes on the cassette. The operative wound should be covered with a sterile towel when anteroposterior view radiographs are made to avoid possible contamination from the machine as it is moved into position. Portable C-arm image intensifier television fluoroscopy allows instantaneous evaluation of the position of fracture fragments and internal fixation devices (Fig. 2.4A and B) . Many of these machines have the ability to make permanent radiographs. When used near the sterile field, the C-arm por- tion of the machine must be draped in a sterile fashion. Every time the C-arm is brought to the lateral position, a fresh or sterile, disposable drape should be applied over the end of the C-arm and dropped off the field when complete. This prevents the potentially contaminated lower half of the drape from get- ting near the patient and operating surgeon. As with any electronic device, failure of an image intensi- fier can occur. In this event, backup plain radiographs are necessary. Two-plane radiographs can be made, even of the hip when necessary, using portable equipment (Fig. 2.4C and D) . Closed intramedullary nailing or percutaneous fracture fixa- tion techniques may need to be abandoned for an open tech- nique if the image intensifier fails. All operating room personnel should avoid exposure to ra- diation. Proper lead-lined aprons should be worn beneath sterile operating gowns. Thyroid shields, lead-impregnated eyeglasses, and rubber gloves are available to decrease exposure. C-arm imaging should be used as a 1- to 2-second pulse to produce a still image for viewing. Active fluoroscopy with the C-arm should be avoided to prevent excessive radiation exposure. CAMPBELL’S CONCEPTS Safety in Tourniquet Use X Tourniquet time should be no longer than 2 hours in an average healthy adult. X Tourniquet pressure is decided based on age, blood pressure, and size of the extremity (135 to 255 mm Hg for upper extremity and 175 to 305 mm Hg for lower extremity are sufficient for maintaining hemostasis). X Instead of increasing pressure in a large extremity, it is better to use a larger cuff. X Avoid straight tourniquets on conical thighs. X Prepare and drape the limb before applying a tourniquet so that any cleansing solution does not run underneath the tourniquet. X Make sure pneumatic tourniquets are in good working order. X In the fingers or toes, rubber ring tourniquets should not be used because they can be forgotten under dressings. X Antibiotics are administered within 1 hour of tourniquet infl ation. X Do not apply a tourniquet over a prosthetic vascular graft. X Prolonged ischemia can result in tourniquet paralysis, post-tourniquet syndrome, compartment syndrome, rhabdomyolysis, and pulmonary embolus. PART I GENERAL PRINCIPLES 140 orthopaedic surgery. A prospective randomized study found that the administration of antibiotics 1 minute after tourniquet inflation resulted in a significantly lower infection rate than the administration of antibiotics 5 minutes before tourniquet infla- tion, suggesting that administration before tourniquet inflation does not give better results. APPLICATION OF A TOURNIQUET The upper arm or the thigh is wrapped with several thick- nesses of smoothly applied cast padding (application of more than two layers of padding results in significant reduction in the actual transmitted pressure). When applying a tourniquet on an obese patient, an assistant manually grasps the flesh of the extremity just distal to the level of tourniquet application and firmly pulls this loose tissue distally before the cast pad- ding is placed. Traction on the soft tissue is maintained while the padding and tourniquet are applied, and the latter is se- cured. The assistant’s grasp is released, resulting in a greater proportion of the subcutaneous tissue remaining distal to the tourniquet. This bulky tissue tends to support the tourniquet and push it into an even more proximal position. All air is expressed from the sphygmomanometer or pneumatic tour- niquet before application. When a sphygmomanometer cuff is used, it should be wrapped with a gauze bandage to prevent its slipping during inflation. The extremity is elevated for 2 minutes, or the blood is expressed by a sterile sheet rubber bandage or a cot- ton elastic bandage. Beginning at the fingertips or toes, the extremity is wrapped proximally to within 2.5 to 5 cm of the tourniquet. If a Martin sheet rubber bandage or an elastic bandage is applied up to the level of the tourniquet, the latter tends to slip distally at the time of inflation. The tourniquet should be inflated quickly to prevent filling of the superficial veins before the arterial blood flow has been occluded. The conical, obese, or muscular lower extremity presents a special challenge. If a curved tourniquet is not available, a straight tourniquet may be used but is difficult to hold in place because it tends to slide distally during skin prepara- tion. Application of adhesive drapes, extra cast padding, and pulling the fat tissue distally before applying the tourniquet generally works. A simple method has been described to keep a tourniquet in place on a large thigh. Surgical lubricating jelly is applied circumferentially to the thigh, and several lay- ers of 6-inch cast padding are applied over the jelly. The tourniquet is then applied. The cast padding adheres to the lubricating jelly-covered skin and reduces the tendency of the tourniquet to slide. COMPLICATIONS WITH TOURNIQUET USE TOURNIQUET PARALYSIS Tourniquet paralysis can result from excessive pressure; in- sufficient pressure that results in passive congestion of the part with hemorrhagic infiltration of the nerve; keeping the tourniquet inflated too long; or application without consider- ation of the local anatomy. There is no rule as to how long a tourniquet may be safely inflated. The time may vary with the B C D A FIGURE 2.3 A, ForgetMeNot tourniquet as supplied. B, Form two loops. C, Place digit in space between two loops and pull proximally to exsanguinate digit. D, Tourniquet in place. (Modifi ed from Diaz HJJ, et al.: The new digit tourniquet ForgetMeNot. Orthop Traumatol Surg Res 104:133, 2018.) Unlock the power of AI in clinical decision making Access Campbell’s Operative Orthopaedics, through ClinicalKey AI, a clinical decision support tool that combines trusted, evidence-based content with advanced generative AI. Learn more about ClinicalKey AI.
Order your copy of Campbell’s Operative Orthopaedics, 4-Volume Set, 15th Edition at elsevierhealth.com/9780443117633 132 PERIOPERATIVE PATIENT OPTIMIZATION AND OVERVIEW OF TENDON-TO-BONE FIXATION AND BONE GRAFTING Omar Medina CHAPTER 2 PREOPERATIVE PATIENT OPTIMIZATION BONE HEALTH Patient preoperative optimization begins during the clinic visit. A thorough conversation and meticulous history taking are vital to patient safety and to obtain an ideal outcome. Knowing the patient’s bone quality before surgery can pre- vent catastrophic outcomes. Osteoporosis has been identified as a public health concern and can lead to low-energy frac- tures and poor postoperative results. Osteoporosis can be screened using a dual-energy x-ray absorptiometry scan. This helps quantify bone density, allowing the provider to closely follow a patient’s bone health, and it may present an opportu- nity for intervention with over-the-counter and prescription medication to reduce risk of fracture in the future. DEEP VEIN THROMBOSIS CONSIDERATIONS REVERSING PROPHYLACTIC ANTICOAGULATION PRIOR TO SURGERY Patients on anticoagulants will usually need reversal before major surgery. Anticoagulation in electively scheduled pa- tients can easily be reversed with medical management be- fore surgery. Tables 2.1 and 2.2 outline procedures for urgent reversal of anticoagulants and give the half-lives of the vari- ous anticoagulants in use if reversal is not as urgent. VENOUS THROMBOEMBOLISM PROPHYLAXIS Patients with acute lower extremity injuries or other injuries requiring bed rest should have prophylactic anticoagulation PREOPERATIVE PATIENT OPTIMIZATION 132 BONE HEALTH 132 DEEP VEIN THROMBOSIS CONSIDERATIONS 132 Reversing prophylactic anticoagulation prior to surgery 132 Venous thromboembolism prophylaxis 132 PREVENTING INFECTION 132 Antibiotics 132 Biologics 136 Diabetic control 136 INTRAOPERATIVE CONSIDERATIONS 136 PREVENTING MISTAKES 136 TOURNIQUETS 136 Tourniquet time 137 Tourniquet pressure 137 Tourniquet safety 138 Preoperative antibiotics and tourniquet use 139 Application of a tourniquet 140 Complications with tourniquet use 140 BLOOD LOSS CONTROL DURING SURGERY 141 RADIOGRAPHS IN THE OPERATING ROOM 141 POSITIONING OF THE PATIENT 142 LOCAL PREPARATION OF THE PATIENT 142 DRAPING 144 Draping the edges of the incision 144 WOUND-IRRIGATING SOLUTIONS 145 PREVENTION OF HUMAN IMMUNODEFICIENCY VIRUS AND HEPATITIS VIRUS TRANSMISSION 145 POSTOPERATIVE PAIN CONTROL 145 OVERVIEW OF TENDON-TO-BONE FIXATION 146 SUTURE FIXATION 146 SUTURE ANCHORS 148 SUTURE BUTTONS 149 OVERVIEW OF BONE GRAFTING 149 STRUCTURE OF BONE GRAFTS 150 SOURCES OF BONE GRAFTS 150 Autogenous grafts Allogenic grafts Cancellous bone graft substitutes INDICATIONS FOR VARIOUS BONE GRAFT TECHNIQUES 151 Onlay cortical grafts 151 Inlay grafts 151 Multiple cancellous chip grafts 151 Hemicylindrical grafts 151 Whole-bone transplant 151 with a readily reversible anticoagulant (heparin or a low-mo- lecular weight heparin) before surgery. Anticoagulation should be continued after surgery until the patient is mobile. Subcuta- neous low-molecular-weight heparin for 10 to 14 days after discharge followed by 4 to 6 weeks of aspirin works well. Patients having elective lower extremity surgery may receive prophylactic anticoagulation immediately after surgery, and this should be continued for 6 to 8 weeks after discharge as outlined above. Patients with bilateral lower extremity injuries that prevent ambulation for a longer period of time require bridging from low-molecular-weight heparin to warfarin, and this is continued with prothrombin time monitoring until the patient is mobile. In patients undergoing spine surgery, close observation is necessary when adding postoperative anticoag- ulation, especially in those with an exposed cord or thecal sac. Consideration for deep vein thrombosis prophylaxis postop- eratively is recommended for those undergoing an anterior approach in which the great vessels are mobilized for exposure of the anterior spine. Prophylaxis also should be considered in those patients who are not mobile after 24 to 48 hours after major spine surgery. All patients requiring surgery should have lower extremity segmental compression devices applied to unoperated lower extremities during surgery and while in bed before and after surgery. PREVENTING INFECTION ANTIBIOTICS Preoperative administration of antibiotics plays a crucial role in reducing postoperative infection complications (see Chapter 22 on infections). Postoperative infections have been shown to not 132 PERIOPERATIVE PATIENT OPTIMIZATION AND OVERVIEW OF TENDON-TO-BONE FIXATION AND BONE GRAFTING Omar Medina CHAPTER 2 PREOPERATIVE PATIENT OPTIMIZATION BONE HEALTH Patient preoperative optimization begins during the clinic visit. A thorough conversation and meticulous history taking are vital to patient safety and to obtain an ideal outcome. Knowing the patient’s bone quality before surgery can pre- vent catastrophic outcomes. Osteoporosis has been identified as a public health concern and can lead to low-energy frac- tures and poor postoperative results. Osteoporosis can be screened using a dual-energy x-ray absorptiometry scan. This helps quantify bone density, allowing the provider to closely follow a patient’s bone health, and it may present an opportu- nity for intervention with over-the-counter and prescription medication to reduce risk of fracture in the future. DEEP VEIN THROMBOSIS CONSIDERATIONS REVERSING PROPHYLACTIC ANTICOAGULATION PRIOR TO SURGERY Patients on anticoagulants will usually need reversal before major surgery. Anticoagulation in electively scheduled pa- tients can easily be reversed with medical management be- fore surgery. Tables 2.1 and 2.2 outline procedures for urgent reversal of anticoagulants and give the half-lives of the vari- ous anticoagulants in use if reversal is not as urgent. VENOUS THROMBOEMBOLISM PROPHYLAXIS Patients with acute lower extremity injuries or other injuries requiring bed rest should have prophylactic anticoagulation PREOPERATIVE PATIENT OPTIMIZATION 132 BONE HEALTH 132 DEEP VEIN THROMBOSIS CONSIDERATIONS 132 Reversing prophylactic anticoagulation prior to surgery 132 Venous thromboembolism prophylaxis 132 PREVENTING INFECTION 132 Antibiotics 132 Biologics 136 Diabetic control 136 INTRAOPERATIVE CONSIDERATIONS 136 PREVENTING MISTAKES 136 TOURNIQUETS 136 Tourniquet time 137 Tourniquet pressure 137 Tourniquet safety 138 Preoperative antibiotics and tourniquet use 139 Application of a tourniquet 140 Complications with tourniquet use 140 BLOOD LOSS CONTROL DURING SURGERY 141 RADIOGRAPHS IN THE OPERATING ROOM 141 POSITIONING OF THE PATIENT 142 LOCAL PREPARATION OF THE PATIENT 142 DRAPING 144 Draping the edges of the incision 144 WOUND-IRRIGATING SOLUTIONS 145 PREVENTION OF HUMAN IMMUNODEFICIENCY VIRUS AND HEPATITIS VIRUS TRANSMISSION 145 POSTOPERATIVE PAIN CONTROL 145 OVERVIEW OF TENDON-TO-BONE FIXATION 146 SUTURE FIXATION 146 SUTURE ANCHORS 148 SUTURE BUTTONS 149 OVERVIEW OF BONE GRAFTING 149 STRUCTURE OF BONE GRAFTS 150 SOURCES OF BONE GRAFTS 150 Autogenous grafts Allogenic grafts Cancellous bone graft substitutes INDICATIONS FOR VARIOUS BONE GRAFT TECHNIQUES 151 Onlay cortical grafts 151 Inlay grafts 151 Multiple cancellous chip grafts 151 Hemicylindrical grafts 151 Whole-bone transplant 151 with a readily reversible anticoagulant (heparin or a low-mo- lecular weight heparin) before surgery. Anticoagulation should be continued after surgery until the patient is mobile. Subcuta- neous low-molecular-weight heparin for 10 to 14 days after discharge followed by 4 to 6 weeks of aspirin works well. Patients having elective lower extremity surgery may receive prophylactic anticoagulation immediately after surgery, and this should be continued for 6 to 8 weeks after discharge as outlined above. Patients with bilateral lower extremity injuries that prevent ambulation for a longer period of time require bridging from low-molecular-weight heparin to warfarin, and this is continued with prothrombin time monitoring until the patient is mobile. In patients undergoing spine surgery, close observation is necessary when adding postoperative anticoag- ulation, especially in those with an exposed cord or thecal sac. Consideration for deep vein thrombosis prophylaxis postop- eratively is recommended for those undergoing an anterior approach in which the great vessels are mobilized for exposure of the anterior spine. Prophylaxis also should be considered in those patients who are not mobile after 24 to 48 hours after major spine surgery. All patients requiring surgery should have lower extremity segmental compression devices applied to unoperated lower extremities during surgery and while in bed before and after surgery. PREVENTING INFECTION ANTIBIOTICS Preoperative administration of antibiotics plays a crucial role in reducing postoperative infection complications (see Chapter 22 on infections). Postoperative infections have been shown to not 132 PERIOPERATIVE PATIENT OPTIMIZATION AND OVERVIEW OF TENDON-TO-BONE FIXATION AND BONE GRAFTING Omar Medina CHAPTER 2 PREOPERATIVE PATIENT OPTIMIZATION BONE HEALTH Patient preoperative optimization begins during the clinic visit. A thorough conversation and meticulous history taking are vital to patient safety and to obtain an ideal outcome. Knowing the patient’s bone quality before surgery can pre- vent catastrophic outcomes. Osteoporosis has been identified as a public health concern and can lead to low-energy frac- tures and poor postoperative results. Osteoporosis can be screened using a dual-energy x-ray absorptiometry scan. This helps quantify bone density, allowing the provider to closely follow a patient’s bone health, and it may present an opportu- nity for intervention with over-the-counter and prescription medication to reduce risk of fracture in the future. DEEP VEIN THROMBOSIS CONSIDERATIONS REVERSING PROPHYLACTIC ANTICOAGULATION PRIOR TO SURGERY Patients on anticoagulants will usually need reversal before major surgery. Anticoagulation in electively scheduled pa- tients can easily be reversed with medical management be- fore surgery. Tables 2.1 and 2.2 outline procedures for urgent reversal of anticoagulants and give the half-lives of the vari- ous anticoagulants in use if reversal is not as urgent. VENOUS THROMBOEMBOLISM PROPHYLAXIS Patients with acute lower extremity injuries or other injuries requiring bed rest should have prophylactic anticoagulation PREOPERATIVE PATIENT OPTIMIZATION 132 BONE HEALTH 132 DEEP VEIN THROMBOSIS CONSIDERATIONS 132 Reversing prophylactic anticoagulation prior to surgery 132 Venous thromboembolism prophylaxis 132 PREVENTING INFECTION 132 Antibiotics 132 Biologics 136 Diabetic control 136 INTRAOPERATIVE CONSIDERATIONS 136 PREVENTING MISTAKES 136 TOURNIQUETS 136 Tourniquet time 137 Tourniquet pressure 137 Tourniquet safety 138 Preoperative antibiotics and tourniquet use 139 Application of a tourniquet 140 Complications with tourniquet use 140 BLOOD LOSS CONTROL DURING SURGERY 141 RADIOGRAPHS IN THE OPERATING ROOM 141 POSITIONING OF THE PATIENT 142 LOCAL PREPARATION OF THE PATIENT 142 DRAPING 144 Draping the edges of the incision 144 WOUND-IRRIGATING SOLUTIONS 145 PREVENTION OF HUMAN IMMUNODEFICIENCY VIRUS AND HEPATITIS VIRUS TRANSMISSION 145 POSTOPERATIVE PAIN CONTROL 145 OVERVIEW OF TENDON-TO-BONE FIXATION 146 SUTURE FIXATION 146 SUTURE ANCHORS 148 SUTURE BUTTONS 149 OVERVIEW OF BONE GRAFTING 149 STRUCTURE OF BONE GRAFTS 150 SOURCES OF BONE GRAFTS 150 Autogenous grafts Allogenic grafts Cancellous bone graft substitutes INDICATIONS FOR VARIOUS BONE GRAFT TECHNIQUES 151 Onlay cortical grafts 151 Inlay grafts 151 Multiple cancellous chip grafts 151 Hemicylindrical grafts 151 Whole-bone transplant 151 with a readily reversible anticoagulant (heparin or a low-mo- lecular weight heparin) before surgery. Anticoagulation should be continued after surgery until the patient is mobile. Subcuta- neous low-molecular-weight heparin for 10 to 14 days after discharge followed by 4 to 6 weeks of aspirin works well. Patients having elective lower extremity surgery may receive prophylactic anticoagulation immediately after surgery, and this should be continued for 6 to 8 weeks after discharge as outlined above. Patients with bilateral lower extremity injuries that prevent ambulation for a longer period of time require bridging from low-molecular-weight heparin to warfarin, and this is continued with prothrombin time monitoring until the patient is mobile. In patients undergoing spine surgery, close observation is necessary when adding postoperative anticoag- ulation, especially in those with an exposed cord or thecal sac. Consideration for deep vein thrombosis prophylaxis postop- eratively is recommended for those undergoing an anterior approach in which the great vessels are mobilized for exposure of the anterior spine. Prophylaxis also should be considered in those patients who are not mobile after 24 to 48 hours after major spine surgery. All patients requiring surgery should have lower extremity segmental compression devices applied to unoperated lower extremities during surgery and while in bed before and after surgery. PREVENTING INFECTION ANTIBIOTICS Preoperative administration of antibiotics plays a crucial role in reducing postoperative infection complications (see Chapter 22 on infections). Postoperative infections have been shown to not
Order your copy of Campbell’s Operative Orthopaedics, 4-Volume Set, 15th Edition at elsevierhealth.com/9780443117633 133 CHAPTER 2 PERIOPERATIVE PATIENT OPTIMIZATION AND OVERVIEW OF TENDON-TO-BONE FIXATION AND BONE GRAFTING ANTITHROMBOTIC REVERSAL AGENT(S) COMMENTS DTIs PO: ■ Dabigatran (Pradaxa): half-life 12–17 hr in normal renal function Note*** Clearance is reduced and half-life is prolonged in renal dysfunction. Correlate to clinical presenta- tion when consid- ering reversal. Idarucizumab (Praxbind) — only used for reversal of dabigatran (Pradaxa) Restrictions: Patients confirmed to have recent dabigatran use who: ■ Require anticoagulant reversal for life-threatening hemorrhage, OR ■ Require urgent/emergent invasive procedure within the next 8 hours Dose: 5 g Administration: ■ Infuse two 2.5 g/50 mL vials undiluted over 5–10 min each, consecutively ■ Line should be flushed with NS prior to infusion ■ Second vial should be infused within 15 min of first vial Onset: Immediate Kcentra—4 Factor PCC (May be considered for dabigatran reversal if idaruci- zumab not available) Dose *: 1500 units 1 (optional rescue dose of 1500 units available if hemostasis not achieved) Administration: ■ Send Kcentra kit for bedside reconstitution and administer via IV push over 5 min ■ Use within 4 hr of reconstitution Onset: 30 min Caution: thrombotic risk Kcentra contains trace amounts of heparin (to mitigate thrombotic potential) and should not be used in bleeding patients with active or recent (last 100 days) HIT. In this instance, please contact pharmacy to discuss possible use of the alternative procoagulant FEIBA for reversal. Use of PCC/idarucizumab: ■ REQUIRES ATTENDING APPROVAL ■ Document attending name in the order comments Additional options: ■ If dabigatran ingested within 1 hour, consider activated charcoal ■ Mechanical methods, such as dialysis, may be considered as a last resort Laboratory measurement: ■ A normal thrombin time rules out clinically relevant dabigatran effect ■ Do not use INR to guide management IV: ■ Argatroban ■ Bivalirudin (Angiomax ® ): half-life 10–90 min Note*** Clearance of bivali- rudin is reduced and half-life is prolonged in renal dysfunction. Correlate to clinical presentation when considering reversal. IV DTIs: ■ Short half-life and discontinuation of IV DTIs are primary means of attenuating bleed ■ Support with crystalloid and blood products to facilitate rapid renal clearance of drug ■ IV DTIs should be discontinued immediately upon bleeding discovery and rarely require other means of reversal Factor Xa inhibitors ■ Fondaparinux (Arixtra ® ): half-life 17–21 hr in normal renal function ■ Rivaroxaban (Xarelto ® ): half-life 5–9 hr ■ Apixaban (Eliquis ® ): half-life 8–15 hr ■ Edoxaban (Savaysa ® ): half-life 10–14 hr Note*** Clearance is reduced and half-life is prolonged in renal dysfunction. Correlate to clinical presenta- tion when consid- ering reversal. Kcentra ® (Inactive 4 factor PCC) Dose *: 1500 units 1 (optional rescue dose of 1500 units available if hemostasis not achieved) Administration: ■ Send Kcentra Kit for bedside reconstitution and administer via IV push over 5 min ■ Use within 4 hr of reconstitution Onset: 30 min Caution: thrombotic risk Kcentra contains trace amounts of heparin (to mitigate thrombotic potential) and should not be used in bleeding patients with active or recent (last 100 days) HIT. In this instance, please contact pharmacy to discuss possible use of the alternative procoagulant FEIBA for reversal. rFVIIa (if refractory to Kcentra) Dose *: ■ 100 mcg/kg (dose cap at 100 kg to mitigate thrombotic risk) ■ May repeat in 2 hr if continued bleeding Administration: ■ IV bolus over 3–5 min ■ Use within 3 hr of reconstitution Onset: 30 min Caution: thrombotic risk Use of PCC: ■ REQUIRES ATTENDING APPROVAL ■ Document attending name in the order comments Additional options: ■ If rivaroxaban, apixa- ban, or edoxaban ingested within 1 hr, consider activated charcoal ■ NOT DIALYZABLE Laboratory measurement: ■ An undetectable stan- dard UFH/LMWH anti- factor Xa level (0.04 IU/ mL) rules out clinically relevant drug effect ■ Do not use INR to guide management TABLE 2.1 Anticoagulant Reversal Continued
Order your copy of Campbell’s Operative Orthopaedics, 4-Volume Set, 15th Edition at elsevierhealth.com/9780443117633 PART I GENERAL PRINCIPLES 134 TABLE 2.1 Anticoagulant Reversal—cont’d ANTITHROMBOTIC REVERSAL AGENT(S) COMMENTS Heparin: half-life 1–2 hr Protamine Dose: 1 mg reverses 100 units of IV-administered UFH ■ Prophylactic SQ doses are not likely to cause significant hemorrhage ■ Look for other causes of hemorrhage Laboratory measurement: ■ If anti-Xa or aPTT re- mains elevated or if bleeding is not con- trolled, may redose with 50 mg ■ Consider FFP and other blood product support TIME SINCE UFH DOSE PER 100 UNITS UFH OVER LAST 3 HR � 30 min 1.0 mg 30–120 min 0.5 mg � 120 min 0.25 mg ■ Do not exceed 50 mg in a single dose: high doses can have an undesirable anticoagulant effect ■ In clinical practice, give 50 mg IV 1 over 10 min; may redose if bleeding continues Administration: Slow IV push not to exceed 5 mg/min Onset: 5–15 min Caution: Rapid administration can cause severe hypotension and anaphylaxis LMWHs (enoxaparin): half-life 5–7 hr in normal renal function Note*** Clearance is reduced and half-life is prolonged in renal dysfunction. Correlate to clinical presenta- tion when consid- ering reversal. If active bleeding, check anti-Xa regardless of time since last administration and if greater than 0.2 IU/mL, consider reversal If no active bleeding and � 12 hr have elapsed since LMWH administration, prot- amine may not be needed and the decision to reverse should be correlated with the clinical situation Protamine (does not reverse LMWH as effectively as it does UFH) Dose: 1 mg for each 1 mg of enoxaparin in last 8 hr If � 12 hr have elapsed since LMWH administration, protamine may not be needed Do not exceed 50 mg in a single dose; high doses can have an undesirable ANTIcoagulant effect In clinical practice, give 50 mg IV � 1 over 10 min Administration: Slow IV push not to exceed 5 mg/min Onset: 5–15 min Caution: Rapid administration can cause severe hypotension and anaphylaxis Laboratory measurement: ■ If anti-Xa remains ele- vated or bleeding not controlled, may give second dose of 0.5 mg protamine per 1 mg LMWH ■ Consider FFP and other blood product support Warfarin: half-life 36 hr ACTIVE BLEEDING AT ANY INR: ■ Hold warfarin and give Vit K 5–10 mg IV (may repeat q12h based on repeat INR) MAJOR OR LIFE-THREATENING BLEED: ■ Hold warfarin and give Vit K 10 mg IV (may repeat q12h based on repeat INR) PLUS either Kcentra (preferred) or FFP ■ Kcentra 1500 units � 1 OR ■ FFP 10–30 mL/kg ASYMPTOMATIC SUPRATHERAPEUTIC INR (i.e., no active bleeding): ■ INR 5–9: Omit 1–2 warfarin doses � may consider 1–2.5 mg PO Vit K in select cases ■ INR � 9 (NO BLEED): Omit 1–2 warfarin doses and give 2.5–5 mg PO Vit K Surgery reversal: INR � 1.5–2.5 ■ Surgery � 24 hr: 0.5–1 mg IV vitamin K � 1; � 5–8 mL/kg FFP ■ Surgery 24–96 hr: 0.5–1 mg PO vitamin K � 1; monitor INR q12–24 hr INR � 2.5–5 ■ Surgery � 24 hr: 1–2.5 mg IV vitamin K � 1; � 5–8 mL/kg FFP ■ Surgery 24–96 hr: 1–2.5 mg PO vitamin K � 1; monitor INR q12–24 hr Phytonadione (Vitamin K) Dose: See box on left Administration: IV-dilute in 50 mL NS and give over 30 min Onset: PO � 24 hr; IV � 12 hr Caution: IV—may be associated with very small risk of anaphylaxis FFP Dose: See box on left Administration: At least 10 mL/min Onset: 2–6 hr Caution: Carries risk of infection, must be thawed and a large volume is required (often � 1 L) Kcentra Dose: 1500 units � 1 (optional rescue dose of 1500 units available if hemostasis or desired target INR not achieved) Administration: Send Kcentra Kit for bedside reconstitution and admin- ister via IV push over 5 min Use within 4 hr of reconstitution Onset: � 30 min Caution: thrombotic risk Kcentra contains trace amounts of heparin (to mitigate thrombotic potential) and should not be used in bleeding patients with active or recent (last 100 days) HIT. In this instance, please contact pharmacy to discuss possible use of the alterna- tive procoagulant FEIBA (activated 4 factor PCC) for reversal. Use of Kcentra: ■ REQUIRES PCP APPROVAL ■ Document attending name in the order comments Laboratory measurement: ■ Repeat INR 30 min after Kcentra infusion ■ If INR remains elevated, may give additional 1500 units � 1
Order your copy of Campbell’s Operative Orthopaedics, 4-Volume Set, 15th Edition at elsevierhealth.com/9780443117633 135 CHAPTER 2 PERIOPERATIVE PATIENT OPTIMIZATION AND OVERVIEW OF TENDON-TO-BONE FIXATION AND BONE GRAFTING * Doses are not based on high-quality evidence and are intended as suggestions only. Consider antifi brinolytics for refractory bleeding: ■ Aminocaproic acid Mechanism: antifibrinolytic ■ Dose: 4–5 g loading dose in 250 mL NS over 15 min followed by infusion of 1 g/hr infusion until bleeding subsides (maximum 30 g/day) ■ Caution: May require renal adjustment ■ Tranexamic acid Mechanism: antifibrinolytic ■ Dose: 1000 mg IV over 10–20 min. If bleeding continues after initial dose, could consider additional 1000 mg dose IV over 10–20 min. Quantra (QSTAT) may be helpful in guiding need for additional doses. ■ Caution: May require renal adjustment. Higher total doses ( � 50 mg/kg) may increase risk of seizures. DDAVP, Desmopressin; DTI, direct thrombin inhibitor; FEIBA, factor eight inhibitor bypassing activity; FFP, fresh frozen plasma; HIT, heparin-induced thrombocytopenia; INR, International Normalized Ratio; IV, intravenous; LMWH, low-molecular-weight heparin; NIHSS, National Institutes of Health Stroke Scale; NS, normal saline; PCC, prothrombin complex concentrates (Kcentra); rVIIa, recombinant active factor VIIa (NovoSeven); SQ, subcutaneous; UFH, unfractionated heparin. From Dilworth T, Burnett A, Tawil I, Garcia D, Fletcher M: Guideline for antithrombotic reversal. UNM Health System. Anticoagulation Subcommittee, UNMH P&T Committee. Updated December 2024. PDF downloads from here: https://hospitals.health.unm.edu/intranet7/apps/doc_management/index.cfm?document_id � 198547. HALF-LIFE REVERSAL AGENT COMMENTS Aspirin 15–30 min 5–10 days for platelet recovery DDAVP Dose: 0.3 mcg/kg IV � 1 Administration: over 15 min Onset: Immediate Caution: Serial doses associated with tachyphylaxis, hyponatremia, and seizures ■ Short half-life and discontinua- tion of GP IIb–IIIa are primary means of attenuating bleed ■ Transfusion of functioning plate- lets in spontaneous intracranial hemorrhage has been associated with harm and should generally be avoided ■ Mechanical methods, such as dialysis, may be considered as a last resort Clopidogrel (Plavix ® ) 8 hr 5–7 days for platelet recovery Prasugrel (Effient ® ) 7 hr 5–7 days for platelet recovery Ticagrelor (Brilinta ® ) 9 hr 3 days for platelet recovery GP IIb–IIIa Eptifibatide (Integrilin ® ) Abciximab (ReoPro ® ) Tirofiban (Aggrastat ® ) 30–120 min TABLE 2.2 Antiplatelet Reversal Doses are not based on high-quality evidence. DDAVP, Desmopressin. From Dilworth T, Burnett A, Tawil I, Garcia D, Fletcher M. Guideline for antithrombotic reversal. UNM Health System. Anticoagulation Subcommittee, UNMH P&T Committee. Updated December 2024. https://hospitals.health.unm.edu/intranet7/apps/doc_management/index.cfm?document_id � 198547. TABLE 2.1 Anticoagulant Reversal—cont’d ANTITHROMBOTIC REVERSAL AGENT(S) COMMENTS Thrombolytics ■ Alteplase (Activase RT-PA ® ) Terminal half-life: 26–77 min ■ Tenecteplase (TNKase ® ) Terminal half-life: 90–138 min Consider lytic reversal for clinical neuro- logic deterioration defined by � 4 points in NIHSS and hemorrhage as the predom- inant cause of deterioration within 22–36 hr of alteplase or tenecteplase Cryoprecipitate Dose: 10 units Administration: Can be administered as rapidly as tolerated. Must be thawed prior to administration. Expect a 30-min delay after ordering. Tranexamic acid (TXA) Dose: 1 g Administration: 1 g IV or 10–20 min at a rate not to exceed 100 mg/min Consider TXA if cryoprecipitate is contraindicated, declined by patient/ family, or not available in a timely manner Laboratory measurement: ■ Repeat fibrinogen lab 60 min after cryopre- cipitate infusion ■ If fibrinogen level re- mains � 150 mg/dL, may give additional 10 units cryoprecipitate � 1
Order your copy of Campbell’s Operative Orthopaedics, 4-Volume Set, 15th Edition at elsevierhealth.com/9780443117633 PART I GENERAL PRINCIPLES 136 only place a large burden in terms of morbidity on the patient but also to increase the length of hospital stays and return to the operating room and to raise the risk of mortality as well as the cost of health care. The American Academy of Ortho- pedic Surgeons recommend prophylactic antibiotics 1 hour before making the incision. Cefazolin and vancomycin often are administered and discontinued 24 hours after surgery. The Infectious Diseases Society of America recommend ce- fazolin as the antibiotic of choice for orthopaedics. BIOLOGICS Patients with orthopaedic conditions also may have various rheumatologic diseases. Consideration of the patient’s current medication regimen is important. Postoperative complications and infections in patients on biologics have been well docu- mented. However, new data suggest that some medications can be continued through surgery. The American College of Rheu- matology and the American Association of Hip and Knee Surgeons have put together a chart outlining guidelines for the perioperative management of disease-modifying medications for adults with rheumatologic diseases undergoing total knee or hip arthroplasty (Tables 2.3 and 2.4 ) . DIABETIC CONTROL Diabetes is incredibly common, and these patients often have orthopaedic injuries. The increased complication rates after sur- gery in this population are well known. They include increased risk of infection, wound dehiscence, longer hospital stay, renal disease, and longer recovery. Current recommendations are for patients to have a hemoglobin A1c of less than or equal to 8 be- fore undergoing orthopaedic surgery (see Chapter 22 for discus- sion on glycemic control). INTRAOPERATIVE CONSIDERATIONS There are several techniques that are especially important in orthopaedics: use of tourniquets, use of radiographs and image intensifiers in the operating room, positioning of the patient, local preparation of the patient, and draping of the appropriate part or parts. PREVENTING MISTAKES Before entering the operating room, the surgeon and the awake, alert patient should agree on the planned procedure and the surgical site. The surgeon should mark this clearly with his or her initials to prevent a “wrong site” error. Once the patient is under anesthesia, a designated member of the team should state the name of the patient, the procedure, and the correct site. All members of the team should be in agreement. This statement should be clear, concise, and not contain unnecessary informa- tion. A short statement is more likely to be closely heard. This statement should preferably be made after draping. TOURNIQUETS Operations on the extremities are made easier using a tourniquet. The tourniquet is a potentially dangerous instrument that must be used with proper knowledge and care. In some procedures, a MEDICATIONS DOSING INTERVAL RECOMMENDED TIMING OF SURGERY SINCE LAST MEDICATION DOSE DMARDs: CONTINUE THESE MEDICATIONS THROUGH SURGERY (ALL PATIENTS) Methotrexate Weekly Anytime Sulfasalazine Once or twice daily Anytime Hydroxychloroquine Once or twice daily Anytime Leflunomide (Arava) Daily Anytime Doxycycline Daily Anytime Apremilast (Otezla) Twice daily Anytime SEVERE SLE-SPECIFIC MEDICATIONS*: CONTINUE THESE MEDICATIONS IN THE PERIOPERATIVE PERIOD IN CONSULTATION WITH THE TREATING RHEUMATOLOGIST Mycophenolate mofetil Twice daily Anytime Azathioprine Daily or twice daily Anytime Cyclosporine Twice daily Anytime Tacrolimus Twice daily (IV and PO) Anytime Rituximab (Rituxan) Every 4–6 months IV Month 4–6 Belimumab (Benlysta) Weekly SQ Anytime Belimumab (Benlysta) Monthly IV Week 4 Anifrolumab (Saphnelo) Every 4 weeks IV Week 4 Voclosporin (Lupkynis) Twice daily Continue TABLE 2.3 Medications to Continue through Surgery * ”Severe SLE” indicates an organ-threatening disease (2017 American College of Rheumatology/American Association of Hip and Knee Surgeons guideline for periopera- tive management of antirheumatic medication in patients with rheumatic diseases undergoing elective total hip or total knee arthroplasty). DMARDS, Disease-modifying antirheumatic drugs; IV, intravenous; PO, oral; SLE, systemic lupus erythematosus; SQ, subcutaneous. From Goodman SM, Springer BD, Chen AF, et al.: 2022 American College of Rheumatology/American Association of Hip and Knee Surgeons Guideline for the Perioperative Management of Antirheumatic Medication in Patients with Rheumatic Diseases Undergoing Elective Total Hip or Total Knee Arthroplasty, Arthritis Care Res (Hoboken) 74(9):1399, 2022.
Order your copy of Campbell’s Operative Orthopaedics, 4-Volume Set, 15th Edition at elsevierhealth.com/9780443117633 137 CHAPTER 2 PERIOPERATIVE PATIENT OPTIMIZATION AND OVERVIEW OF TENDON-TO-BONE FIXATION AND BONE GRAFTING From Goodman SM, Springer BD, Chen AF, et al.: 2022 American College of Rheumatology/American Association of Hip and Knee Surgeons guideline for the periopera- tive management of antirheumatic medication in patients with rheumatic diseases undergoing elective total hip or total knee arthroplasty, Arthritis Care Res (Hoboken) 74(9):1399, 2022. Bold italic type indicates recommendation that has changed since 2017. The dosing intervals were obtained from prescribing information provided online by phar- maceutical companies. IV, Intravenous; PO, oral; SLE, systemic lupus erythematosus; SQ, subcutaneous. *Drug added for 2022 update. † Recommendation pertains to infection risk and does not account for risk of cardiac events or venous thromboembolism. ‡ For patients with rheumatoid arthritis, ankylosing spondylitis, psoriatic arthritis, or all SLE for whom antirheumatic therapy was held prior to undergoing total joint arthroplasty, restarting the antirheumatic therapy once the wound shows evidence of healing, any sutures/staples are out, there is no significant swelling, erythema or drainage, and there is no ongoing nonsurgical site infection, which is typically about 14 days. tourniquet is a luxury, whereas in others, such as delicate opera- tions on the hand, it is a necessity. A pneumatic tourniquet is safer than an Esmarch tourniquet or a Martin sheet rubber bandage. A pneumatic tourniquet with a hand pump and an accurate pres- sure gauge probably is the safest, but a constantly regulated pres- sure tourniquet is satisfactory if it is properly maintained and checked. A tourniquet should be applied by an individual experi- enced in its use. Several sizes of pneumatic tourniquets are avail- able for the upper and lower extremities. TOURNIQUET TIME Every effort is made to decrease tourniquet time; the extrem- ity often is prepared and ready before the tourniquet is in- flated. In an average healthy adult younger than 50 years of age, we prefer to leave the tourniquet inflated for no more than 2 hours. See Table 2.5 for published recommendations on duration of tourniquets. If surgery is significantly delayed, both lower extremities should be studied with Doppler ultra- sonography for the presence of deep venous thrombi. If pres- ent, the patient should receive full anticoagulation treatment and the procedure delayed. If the procedure is emergent, in- sertion of an inferior vena cava filter should be considered. There have been case reports describing fatal or near fatal pulmonary emboli after exsanguination of a leg. TOURNIQUET PRESSURE The exact pressure to which the tourniquet should be inflated has not been determined (see Table 2.5 ). The correct pressure MEDICATIONS DOSING INTERVAL RECOMMENDED TIMING OF SURGERY BIOLOGICS: WITHHOLD THESE MEDICATIONS THROUGH SURGERY Infliximab (Remicade) Every 4, 6, or 8 weeks Weeks 5, 7, or 9 Adalimumab (Humera) Every 2 weeks Week 3 Etanercept (Enbrel) Every week Week 2 Golimumab (Simponi) Every 4 weeks (SQ) or Every 8 weeks (IV) Week 5 Week 9 Abatacept (Orencia) Monthly (IV) or Weekly (SQ) Week 5 Week 2 Certolizumab (Cimzia) Every 2 or 4 weeks Week 3 or 5 Rituximab (Rituxan) 2 doses 2 weeks apart every 4–6 months Month 7 Tocilizumab (Acetemra) Every week (SQ) or Every 4 weeks (IV) Week 2 Week 5 Anakinra (Kineret) Daily Day 2 IL-17-Secukinumab (Consentyx) Every 4 weeks Week 5 Ustekinumab (Stelara) Every 12 weeks Week 13 Ixekizumab (Taltz)* Every 4 weeks Week 5 IL-23 Guselkumab (Tremfya)* Every 8 weeks Week 9 JAK INHIBITORS: WITHHOLD THIS MEDICATION 3 DAYS PRIOR TO SURGERY † Tofactinib (Xeljanz) Daily or twice daily Day 4 Baricitinib (Olumiant)* Daily Day 4 Upadacitinib (Rinvoq)* Daily Day 4 NOT-SEVERE SLE: WITHHOLD THESE MEDICA- TIONS 1 WEEK PRIOR TO SURGERY Mycophenolate mofetil Twice daily 1 week after last dose Azathioprine Daily or twice daily 1 week after last dose Cyclosporine Twice daily 1 week after last dose Tacrolimus Twice daily (IV and PO) 1 week after last dose Rituximab (Rituxan) Every 4–6 months Month 7 Belimumab IV (Benlysta) Monthly Week 5 Belimumab SQ (Benlysta) Weekly Week 2 TABLE 2.4 Medications to Withhold Prior to Surgery ‡
Order your copy of Campbell’s Operative Orthopaedics, 4-Volume Set, 15th Edition at elsevierhealth.com/9780443117633 PART I GENERAL PRINCIPLES 138 depends on the age of the patient, the blood pressure, and the size of the extremity. Reid et al. used pneumatic tourniquet pressures determined by the pressure required to obliterate the peripheral pulse (limb occlusion pressure) using a Doppler stethoscope; they then added 50 to 75 mm Hg to allow for col- lateral circulation and blood pressure changes. Tourniquet pressures of 135 to 255 mm Hg for the upper extremity and 175 to 305 mm Hg for the lower extremity were satisfactory for maintaining hemostasis. Wide tourniquet cuffs are more effective at lower infla- tion pressures than are narrow ones. Curved tourniquets on conical extremities require significantly lower arterial oc- clusion pressures than straight (rectangular) tourniquets (Fig. 2.1 ) . The use of straight tourniquets on conical thighs should be avoided, especially in extremely muscular or obese individuals. TOURNIQUET SAFETY Any solution applied to skin must not be allowed to run be- neath the tourniquet, or a chemical burn may result. A cir- cumferential adhesive-backed plastic drape applied to the skin just distal to the tourniquet prevents solutions from running under the tourniquet. Sterile pneumatic tourniquets are avail- able for operations around the elbow and knee. The limb may be prepared and draped before the tourniquet is applied. Rarely, a superficial slough of the skin may occur at the upper margin of the tourniquet in the region of the gluteal fold. This slough usually occurs in obese individuals and is probably related to the use of a straight, instead of a curved, tourniquet. PNEUMATIC TOURNIQUETS Pneumatic tourniquets should be kept in good repair, and all valves and gauges must be checked routinely. The inner tube should be completely enclosed in a casing to prevent the tube from ballooning through an opening, allowing the pressure to fall or causing a “blowout.” The cuff also should be inspected carefully. Single-use sterile disposable tourniquets are preferable because reusable tourniquets must be thoroughly decontami- nated after each use to prevent microbial colonization. Any aneroid gauge must be calibrated frequently. Newer gauges carry instruction cards with them. They are sold with test gauges so that the gauges on the tourniquets can be tested for proper calibration. Many automatic tourniquet control units will self-test when turned on. If there is a dis- crepancy, the unit must be manually checked with a test gauge. If the discrepancy is more than 20 mm Hg, the unit should be repaired or replaced. One of the greatest dangers in the use of a tourniquet is an improperly registering gauge; gauges have been found to be 300 mm off calibration. In ORGANIZATION/STUDY PRESSURE DURATION (MIN) REPERFUSION INTERVAL Association of Surgical Technologists Upper extremity, 50 mm Hg above SBP; lower extremity, 100 mm Hg above SBP Upper extremity, 60; lower extremity, 90 15 min Association of Perioperative Registered Nurses 40 mm Hg above LOP for LOP 130 mm Hg; 60 mm Hg above LOP for LOP 131–190 mm Hg; 80 mm Hg above LOP for LOP 190 mm Hg Upper extremity, 60; lower extremity, 90 15 min deflation after every 1 h of tourniquet time Wakai et al. General recommendation, 50–75 mm Hg above LOP; upper extremity, 50–75 mm Hg above SBP; lower extremity, 90–150 mm Hg above SBP 120 30 min at 2-h point in surgery lasting 3 h Kam et al. 50–150 mm Hg above SBP, using the lower end of the range for the upper extremity and the higher end for the lower extremity 120 10 min at the 2-h point for surgery lasting 2 h Noordin et al. Use LOP; no margin specified 120 NR TABLE 2.5 Published Recommendations on Tourniquet Use From Fitzgibbons PG, DiGiovanni C, Hares S, Akelman E: Safe tourniquet use: A review of the literature, J Am Acad Orthop Surg 20:310, 2012. LOP, Limb occlusion pressure; NR, no recommendation; SBP, systolic blood pressure. Cylinder A B Straight cuff Cone Curved cuff FIGURE 2.1 A, Straight (rectangular) tourniquets fit opti- mally on cylindrical limbs. B, Curved tourniquets best fit conical limbs. (From Pedowitz RA, Gershuni DH, Botte MJ, et al.: The use of lower tourniquet inflation pressures in extremity surgery facilitated by curved and wide tourniquets and integrated cuff inflation system, Clin Orthop Relat Res 287:237, 1993.)
Order your copy of Campbell’s Operative Orthopaedics, 4-Volume Set, 15th Edition at elsevierhealth.com/9780443117633 139 CHAPTER 2 PERIOPERATIVE PATIENT OPTIMIZATION AND OVERVIEW OF TENDON-TO-BONE FIXATION AND BONE GRAFTING many tourniquet injuries, the gauges were later checked and found to be grossly inaccurate, allowing excessive pressure. Pneumatic tourniquets usually are applied to the upper arm and thigh, and a well-padded proximal calf tourniquet is safe for foot and ankle surgery. General guidelines for the safe use of pneumatic tourniquets are outlined in Table 2.6 . ESMARCH TOURNIQUETS The Esmarch tourniquet is still in use in some areas and is the safest and most practical of the elastic tourniquets. It is never used except in the middle and upper thirds of the thigh. This tourniquet has a definite, although limited, use in that it can be applied higher on the thigh than can the pneumatic tour- niquet. The Esmarch tourniquet is applied in layers, one on top of the other; a wide band produces less tissue damage than does a narrow one. MARTIN RUBBER SHEETS A Martin rubber sheet bandage can be safely used as a tourni- quet for short procedures on the foot. The leg is elevated and exsanguinated by wrapping the rubber bandage up over the malleoli of the ankle and securing it with a clamp. The distal portion of the bandage is released to expose the operative area. DIGITAL TOURNIQUETS Special attention should be given when using tourniquets on fingers and toes. NOTE! A rubber ring tourniquet or a tourni- quet made from a glove finger that is rolled onto the digit should not be used because it can be inadvertently left in place under a dressing, resulting in catastrophic loss of the digit. A glove finger or Penrose drain can be looped around the proximal portion of the digit, stretched, and secured with a hemostat. It is difficult to include a hemostat inadvertently in a digital dressing. A modified glove finger with a volar flap will help prevent inadvertently leaving the tourniquet in place after surgery (Fig. 2.2 ) . Commercial digital tourniquets (Fig. 2.3 ) with long tails and bright colors help prevent accidental incorporation of the tourniquet into a dressing. Sterile disposable rubber ring tourniquets are now available for use on the upper and lower extremities. These tourniquets are wrapped in stockinette and are applied by rolling the rubber ring and stockinette up the extremity, which exsanguinates the extremity. The stock- inette is then cut away at the operative site. Rubber ring tourniquets are not indicated in the presence of malignancy, infections, significant skin lesions, unstable fractures or dis- locations, poor peripheral blood flow, edema, or deep ve- nous thrombosis. Sizing of these tourniquets is based on systolic blood pressure. PREOPERATIVE ANTIBIOTICS AND TOURNIQUET USE The use of preoperative prophylactic antibiotics in orthopaedic operations has been accepted practice for over 30 years and decreases the likelihood of postoperative infection. Most be- lieve that these antibiotics should be given prior to inflation of the tourniquet to ensure that the antibiotic is present in the tissues before the incision is made. There has been no consensus as to the interval between antibiotic administration and tourni- quet inflation, with variations in time from 5 to 20 minutes being reported. Our institution recommends administration of cefazolin within 1 hour of tourniquet inflation. Studies have shown that a 1-minute interval resulted in cefazolin concentra- tion in soft tissue and bone at or greater than the minimum inhibitory concentrations for microorganisms encountered in Application Apply only to a healthy limb or with caution to an unhealthy limb Size of tourniquet Arm, 10 cm; leg, 15 cm or wider in large legs Site of application Upper arm; mid/upper thigh ideally Padding At least two layers of orthopaedic felt Skin preparation Occlude to prevent soaking of wool Use 50–100 mm Hg above systolic for the arm; double systolic for the thigh; or arm 200–250 mm Hg, leg 250–350 mm Hg (large cuffs are recommended for larger limbs instead of increasing pressure) Time Absolute maximum 3 h (recovers in 5–7 days) generally not to exceed 2 h Temperature Avoid heating (e.g., hot lights), cool if feasible, and keep tissues moist Documentation Duration and pressure at least weekly calibration and against mercury manom- eter or test maintenance gauge; mainte- nance every 3 months TABLE 2.6 Braithwaite and Klenerman’s Modification of Bruner’s Ten Rules of Pneumatic Tourniquet Use Modified from Kutty S, McElwain JP: Padding under tourniquets in tourniquet controlled surgery: Bruner’s ten rules revisited, Injury 33:75, 2002. A B FIGURE 2.2 A, Cut 1 cm from end of corresponding glove finger, then cut through palm half of glove finger at base and extend both ends of cut longitudinally along backside of glove. Remove remaining glove and finger and apply it to palm side of hand. B, Roll glove finger back to serve as tourniquet. Tourni- quet start time can be written on glove flap. (From Osanai T, Ogino T: Modified digital tourniquet designed to prevent the tourniquet from inadvertently being left in place after the end of the surgery, J Orthop Trauma 24:387, 2010.)
Order your copy of Campbell’s Operative Orthopaedics, 4-Volume Set, 15th Edition at elsevierhealth.com/9780443117633 PART I GENERAL PRINCIPLES 140 orthopaedic surgery. A prospective randomized study found that the administration of antibiotics 1 minute after tourniquet inflation resulted in a significantly lower infection rate than the administration of antibiotics 5 minutes before tourniquet infla- tion, suggesting that administration before tourniquet inflation does not give better results. APPLICATION OF A TOURNIQUET The upper arm or the thigh is wrapped with several thick- nesses of smoothly applied cast padding (application of more than two layers of padding results in significant reduction in the actual transmitted pressure). When applying a tourniquet on an obese patient, an assistant manually grasps the flesh of the extremity just distal to the level of tourniquet application and firmly pulls this loose tissue distally before the cast pad- ding is placed. Traction on the soft tissue is maintained while the padding and tourniquet are applied, and the latter is se- cured. The assistant’s grasp is released, resulting in a greater proportion of the subcutaneous tissue remaining distal to the tourniquet. This bulky tissue tends to support the tourniquet and push it into an even more proximal position. All air is expressed from the sphygmomanometer or pneumatic tour- niquet before application. When a sphygmomanometer cuff is used, it should be wrapped with a gauze bandage to prevent its slipping during inflation. The extremity is elevated for 2 minutes, or the blood is expressed by a sterile sheet rubber bandage or a cot- ton elastic bandage. Beginning at the fingertips or toes, the extremity is wrapped proximally to within 2.5 to 5 cm of the tourniquet. If a Martin sheet rubber bandage or an elastic bandage is applied up to the level of the tourniquet, the latter tends to slip distally at the time of inflation. The tourniquet should be inflated quickly to prevent filling of the superficial veins before the arterial blood flow has been occluded. The conical, obese, or muscular lower extremity presents a special challenge. If a curved tourniquet is not available, a straight tourniquet may be used but is difficult to hold in place because it tends to slide distally during skin prepara- tion. Application of adhesive drapes, extra cast padding, and pulling the fat tissue distally before applying the tourniquet generally works. A simple method has been described to keep a tourniquet in place on a large thigh. Surgical lubricating jelly is applied circumferentially to the thigh, and several lay- ers of 6-inch cast padding are applied over the jelly. The tourniquet is then applied. The cast padding adheres to the lubricating jelly-covered skin and reduces the tendency of the tourniquet to slide. COMPLICATIONS WITH TOURNIQUET USE TOURNIQUET PARALYSIS Tourniquet paralysis can result from excessive pressure; in- sufficient pressure that results in passive congestion of the part with hemorrhagic infiltration of the nerve; keeping the tourniquet inflated too long; or application without consider- ation of the local anatomy. There is no rule as to how long a tourniquet may be safely infl ated. The time may vary with the B C D A FIGURE 2.3 A, ForgetMeNot tourniquet as supplied. B, Form two loops. C, Place digit in space between two loops and pull proximally to exsanguinate digit. D, Tourniquet in place. (Modified from Diaz HJJ, et al.: The new digit tourniquet ForgetMeNot. Orthop Traumatol Surg Res 104:133, 2018.)
Order your copy of Campbell’s Operative Orthopaedics, 4-Volume Set, 15th Edition at elsevierhealth.com/9780443117633 141 CHAPTER 2 PERIOPERATIVE PATIENT OPTIMIZATION AND OVERVIEW OF TENDON-TO-BONE FIXATION AND BONE GRAFTING age of the patient and the vascular supply of the extremity, but we recommend leaving the tourniquet inflated for no more than 2 hours. If an operation on the lower extremity takes longer than 2 hours, it is better to finish it as rapidly as possible than to deflate the tourniquet for 10 minutes and then reinflate it. It has been found that 40 minutes is required for the tissues to return to normal after prolonged use of a tourniquet. Consequently, the previous practice of deflating the tourniquet for 10 minutes seems to be inadequate. POST-TOURNIQUET SYNDROME Post-tourniquet syndrome, as first recognized by Bunnell, is a common reaction to prolonged ischemia and is character- ized by edema, pallor, joint stiffness, motor weakness, and subjective numbness. This complication is thought to be re- lated to the duration of ischemia and not to the mechanical effect of the tourniquet. Post-tourniquet syndrome interferes with early motion and results in increased requirement for narcotics. Spontaneous resolution usually occurs within 1 week. ISCHEMIC COMPLICATIONS Compartment syndrome, rhabdomyolysis, and pulmonary emboli are rare complications of tourniquet use. Rasmussen et al. found that muscle beneath the tourniquet had a greater ischemic response than muscle distal to the tourniquet. One study, using transesophageal echocardiography during ar- throscopic knee surgery, showed that asymptomatic pulmo- nary embolism can occur within 1 minute after tourniquet release. The number of small emboli depended on the dura- tion of tourniquet inflation. Vascular complications can oc- cur in patients with severe arteriosclerosis or prosthetic graft s. A tourniquet should not be applied over a prosthetic vascular graft. BLOOD LOSS CONTROL DURING SURGERY When a tourniquet cannot be used because of the location of the surgical site or when blood loss is expected to be high after tourniquet release, routine blood loss control measures should be readily available. These include electrocautery, gel foam, thrombin, and epinephrine. Preoperative planning for larger procedures should include expected blood loss, and preparation should be made to have donor or autologous blood, or both, available and a blood recycling system (cell- saver) present if needed. The use of the fibrinolytic tranexamic acid (TXA) has become popular in large joint arthroplasty surgery for re- ducing blood loss. Luo et al. performed a prospective, ran- domized, double-blind, controlled study that showed equal efficacy in reducing blood loss in primary total hip surgery when TXA was used orally, topically, or by intravenous infu- sion. TXA was administered 2 g orally 2 hours before sur- gery, 2 g into the wound, or 20 mg/kg intravenously. RADIOGRAPHS IN THE OPERATING ROOM Often it is necessary to obtain radiographs during an ortho- paedic procedure. Radiography technicians who work in the operating room must wear the same clothing and masks as the circulating personnel. These technicians must have a clear understanding of aseptic surgical technique and draping to avoid contaminating the drapes in the operative field. Porta- ble radiograph units used in the operating room should be cleaned regularly and ideally are not used in any other area of the hospital. When an unsterile radiograph cassette is to be intro- duced into the sterile field, it should be placed inside a sterile double pillowcase or sterile plastic bag that is folded over so that the exterior remains sterile. The pillowcase or plastic bag is covered by a large sterile towel, ensuring at least two layers of sterile drapes on the cassette. The operative wound should be covered with a sterile towel when anteroposterior view radiographs are made to avoid possible contamination from the machine as it is moved into position. Portable C-arm image intensifier television fluoroscopy allows instantaneous evaluation of the position of fracture fragments and internal fixation devices (Fig. 2.4A and B) . Many of these machines have the ability to make permanent radiographs. When used near the sterile field, the C-arm por- tion of the machine must be draped in a sterile fashion. Every time the C-arm is brought to the lateral position, a fresh or sterile, disposable drape should be applied over the end of the C-arm and dropped off the field when complete. This prevents the potentially contaminated lower half of the drape from get- ting near the patient and operating surgeon. As with any electronic device, failure of an image intensi- fier can occur. In this event, backup plain radiographs are necessary. Two-plane radiographs can be made, even of the hip when necessary, using portable equipment (Fig. 2.4C and D) . Closed intramedullary nailing or percutaneous fracture fixa- tion techniques may need to be abandoned for an open tech- nique if the image intensifier fails. All operating room personnel should avoid exposure to ra- diation. Proper lead-lined aprons should be worn beneath sterile operating gowns. Thyroid shields, lead-impregnated eyeglasses, and rubber gloves are available to decrease exposure. C-arm imaging should be used as a 1- to 2-second pulse to produce a still image for viewing. Active fluoroscopy with the C-arm should be avoided to prevent excessive radiation exposure. CAMPBELL’S CONCEPTS Safety in Tourniquet Use X Tourniquet time should be no longer than 2 hours in an average healthy adult. X Tourniquet pressure is decided based on age, blood pressure, and size of the extremity (135 to 255 mm Hg for upper extremity and 175 to 305 mm Hg for lower extremity are sufficient for maintaining hemostasis). X Instead of increasing pressure in a large extremity, it is better to use a larger cuff. X Avoid straight tourniquets on conical thighs. X Prepare and drape the limb before applying a tourniquet so that any cleansing solution does not run underneath the tourniquet. X Make sure pneumatic tourniquets are in good working order. X In the fi ngers or toes, rubber ring tourniquets should not be used because they can be forgotten under dressings. X Antibiotics are administered within 1 hour of tourniquet infl ation. X Do not apply a tourniquet over a prosthetic vascular graft. X Prolonged ischemia can result in tourniquet paralysis, post-tourniquet syndrome, compartment syndrome, rhabdomyolysis, and pulmonary embolus.