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World J Orthop. Jan 18, 2022; 13(1): 11-35
Published online Jan 18, 2022. doi: 10.5312/wjo.v13.i1.11
Regional anesthesia for orthopedic procedures: What orthopedic surgeons need to know
Ihab Kamel, Muhammad F Ahmed, Anish Sethi
Ihab Kamel, Muhammad F Ahmed, Anish Sethi, Department of Anesthesiology, Lewis Katz School of Medicine at Temple University, Philadelphia, PA 19140, United States
Author contributions: Kamel I contributed to the manuscript writing, manuscript outline; Sethi A and Ahmed MF contributed to the manuscript writing.
Conflict-of-interest statement: The authors report no conflict of interests.
Open-Access: This article is an open-access article that was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution NonCommercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: https://creativecommons.org/Licenses/by-nc/4.0/
Corresponding author: Ihab Kamel, MD, MEHP, FASA, Professor, Department of Anesthesiology, Lewis Katz School of Medicine at Temple University, 3401 N. Broad Street, Third Floor Outpatient Building, Philadelphia, PA 19140, United States. ihab.kamel@tuhs.temple.edu
Received: March 25, 2021
Peer-review started: March 25, 2021
First decision: June 7, 2021
Revised: July 20, 2021
Accepted: January 10, 2022
Article in press: January 10, 2022
Published online: January 18, 2022
Processing time: 297 Days and 18.3 Hours
Abstract

Regional anesthesia is an integral component of successful orthopedic surgery. Neuraxial anesthesia is commonly used for surgical anesthesia while peripheral nerve blocks are often used for postoperative analgesia. Patient evaluation for regional anesthesia should include neurological, pulmonary, cardiovascular, and hematological assessments. Neuraxial blocks include spinal, epidural, and combined spinal epidural. Upper extremity peripheral nerve blocks include interscalene, supraclavicular, infraclavicular, and axillary. Lower extremity peripheral nerve blocks include femoral nerve block, saphenous nerve block, sciatic nerve block, iPACK block, ankle block and lumbar plexus block. The choice of regional anesthesia is a unanimous decision made by the surgeon, the anesthesiologist, and the patient based on a risk-benefit assessment. The choice of the regional block depends on patient cooperation, patient positing, operative structures, operative manipulation, tourniquet use and the impact of post-operative motor blockade on initiation of physical therapy. Regional anesthesia is safe but has an inherent risk of failure and a relatively low incidence of complications such as local anesthetic systemic toxicity (LAST), nerve injury, falls, hematoma, infection and allergic reactions. Ultrasound should be used for regional anesthesia procedures to improve the efficacy and minimize complications. LAST treatment guidelines and rescue medications (intralipid) should be readily available during the regional anesthesia administration.

Keywords: Orthopedic surgery; Regional anesthesia; Spinal; Epidural; Combined spinal epidural; Peripheral nerve blocks; Neuraxial blocks; Upper extremity; Lower extremity; Interscalene; Supraclavicular; Infraclavicular; Axillary; Femoral; Fascia iliaca; Popliteal; Sciatic; Saphenous; Adductor canal; Lumbar plexus; Brachial plexus; Ankle; iPACK; Complication; Local anesthetic systemic toxicity; Nerve injury; Block failure; Continuous nerve block catheters

Core Tip: Understanding the fundamentals of regional anesthesia techniques for orthopedic surgery is essential for superior clinical outcomes and optimal patient safety. The choice of a regional technique requires a well-informed shared decision making process that encompass the anatomical coverage of the block, density of the block, duration of the block, patient positioning considerations, existing comorbidities, side effects, complications, advantages, disadvantages, positioning and impact on postoperative recovery. A risk-benefit analysis that achieves superior clinical outcomes can be only performed if the perioperative team has a profound understanding of the fundamentals of regional anesthesia administration.