What are the anaesthetic considerations and potential intraoperative complications for Open Reduction Internal Fixation (ORIF) procedures?

Anaesthetic Considerations and Intraoperative Complications for ORIF

For Open Reduction Internal Fixation (ORIF) procedures, neuraxial techniques should be considered preferentially over general anesthesia when appropriate for the surgical site, as they provide superior analgesia and potentially reduce perioperative complications.

Preoperative Considerations

Patient Assessment

• Evaluate for obstructive sleep apnea (OSA) as these patients are especially susceptible to respiratory depression from sedatives, opioids, and inhaled anesthetics 1
• Assess cardiovascular risk factors, particularly for elderly patients or those with pre-existing conditions
• Review anticoagulation status and timing of medications, especially important for neuraxial techniques

Anesthetic Planning

• For superficial procedures, consider local anesthesia or peripheral nerve blocks with or without moderate sedation 1
• For lower extremity ORIF, consider neuraxial techniques (spinal/epidural) as they:
  • Provide excellent analgesia
  • May reduce the stress response to surgery
  • Allow for extended postoperative pain control 1
• For upper extremity ORIF, regional techniques (brachial plexus blocks) offer excellent analgesia with minimal systemic effects

Anesthetic Technique Selection

Neuraxial Anesthesia

• Advantages:

  • Reduced opioid requirements
  • Excellent postoperative pain control
  • May reduce stress response to surgery 1
  • Potentially lower incidence of postoperative respiratory complications
  • Allows for early detection of neurological complications

• Considerations:

  • Use pencil-point spinal needles to minimize post-dural puncture headache risk 1
  • For procedures with unpredictable duration, consider catheter techniques over single-injection 1
  • Combined spinal-epidural techniques provide rapid onset and flexibility for prolonged cases 2

General Anesthesia

• When indicated:

  • For procedures where patient positioning makes neuraxial techniques difficult
  • When neuraxial techniques are contraindicated
  • For prolonged or complex procedures

• Considerations:

  • Either volatile anesthetics or total intravenous anesthesia (TIVA) are reasonable choices, with no evidence favoring one over the other for prevention of myocardial ischemia 1
  • For patients with OSA, secure airway management is preferable to deep sedation 1
  • Full reversal of neuromuscular blockade should be verified before extubation 1

Intraoperative Management

Positioning

• Careful positioning is crucial to prevent nerve injuries, especially for lateral decubitus position in pelvic ORIF
• Consider the duration of surgery and risk of pressure injuries
• For pelvic ORIF, simultaneous anterior and posterior internal fixation may be performed with the patient in lateral decubitus position 3

Hemodynamic Management

• Maintain normotension, avoiding hypotension that may compromise perfusion to surgical site
• Consider invasive arterial monitoring for complex cases or patients with significant comorbidities
• IV fluid preloading or co-loading may reduce frequency of hypotension with neuraxial techniques 1

Temperature Management

• Maintenance of normothermia is reasonable to reduce perioperative cardiac events 1
• Active warming measures should be employed for longer procedures

Potential Intraoperative Complications

Hemorrhage

• Blood loss can be significant, particularly in pelvic ORIF procedures 3
• Have blood products readily available for high-risk cases
• Consider cell salvage techniques for cases with anticipated high blood loss

Venous Thromboembolism (VTE)

• High risk in orthopedic procedures, particularly lower extremity and pelvic ORIF
• Pharmacological prophylaxis with LMWH and well-fitting compression stockings are recommended 1
• Extended prophylaxis (28 days) should be considered for high-risk patients 1

Cement Implantation Syndrome

• Can occur with methylmethacrylate cement use in some ORIF procedures
• Monitor for hypoxia, hypotension, arrhythmias, and increased pulmonary vascular resistance
• Be prepared to provide hemodynamic support if needed

Fat Embolism Syndrome

• Risk increases with long bone fractures
• Monitor for hypoxemia, neurological changes, and petechial rash
• Maintain adequate oxygenation and ventilation

Postoperative Considerations

Pain Management

• Multimodal analgesia approach is essential
• Continue regional or neuraxial techniques when possible
• Neuraxial analgesia for postoperative pain relief can be effective to reduce myocardial infarction in high-risk patients 1

Monitoring

• Patients with OSA should be monitored closely for respiratory depression, particularly if opioids are used 1
• When possible, extubation and recovery should be carried out in lateral, semi-upright, or other non-supine positions for OSA patients 1

Special Considerations

Elderly Patients

• Higher risk of complications (2% within 30 days of distal radius ORIF) 4
• Risk factors include hypertension, congestive heart failure, and impaired independent living 4
• Consider using BIS monitoring to avoid deep levels of anesthesia (BIS < 30) 1

Timing of Surgery

• While early ORIF (within 24 hours) has been advocated for some fractures, evidence suggests that delayed ORIF (>14 days) for ankle fractures does not significantly increase wound complications or impair functional outcomes 5
• The decision on timing should balance medical optimization with the benefits of early mobilization

By carefully considering these anesthetic factors and potential complications, anesthesiologists can significantly contribute to successful outcomes in ORIF procedures across various fracture types.