Prof. Dr. Mohamed Saeed Abd El-aziz Prof. Dr. Sameh Michel

Different Anesthetic Techniques for Knee Arthroscopic
Surgeries
An Essay
Submitted in Partial Fulfillment of the Master’s
Degree in Anesthesia
By
Amr Saeed Hassan El-kholy
M.B., B.Ch.
Supervised by
Prof. Dr. Mohamed Saeed Abd El-aziz
Professor of Anesthesia and Intensive Care
Faculty of Medicine – Ain Shams University
Prof. Dr. Sameh Michel Hakim
Professor of Anesthesia and Intensive Care
Faculty of Medicine – Ain Shams University
Dr. Rasha Gamal Abu Sinna
Lecturer in Anesthesia and Intensive Care
Faculty of Medicine – Ain Shams University
Ain Shams University
Faculty of Medicine
٢٠١٢
‫ﺑﺴﻢ اﷲ اﻟﺮﺣﻤﻦ اﻟﺮﺣﯿﻢ‬
‫" و ﻣﺎ ﺗﻮﻓﯿﻘﻰ إﻻ ﺑﺎﷲ ﻋﻠﯿﮫ ﺗﻮﻛﻠﺖ وإﻟﯿﮫ‬
‫أﻧﯿﺐ"‬
‫ﺻﺪق اﷲ اﻟﻌﻈﯿﻢ‬
‫) ﺳﻮرة ھﻮد ‪ ،‬آﯾﮫ ‪( ٨٨‬‬
Acknowledgments
First and foremost, thanks and praise Allah most gracious, most
merciful
Words stand short when coming to express my deepest gratitude
and greatest thanks to Prof. Dr. Mohamed Saeed Abd El-Aziz
Professor of Anaesthesia and Intensive care, Faculty of medicine,
Ain Shams Univeristy, for his constant encouragement,
constructive guidance and unlimited support all through my
career. Working under his supervision is a real privilege. To him
I feel indeed grateful.
I am also greatly indebted to Prof. Dr. Sameh Michel Hakim
Professor of Anesthesia and Intensive care, Faculty of medicine,
Ain Shams Univeristy, for his supervision, sincere help and
continuing encouragement throughout the whole work.
I would like to direct my special thanks to Dr.Rasha Gamal Abu
Sinna Lecturer of Anaesthesia and Intensive care, Faculty of
medicine, Ain Shams Univeristy, for her irrvaluable help, fruitful
advice, continuous support offered to me and guidance step by
step till this essay finished.
To my beloved family, I will always eternally indebted, for their
continuous encouragement and infinite tolerant support.
Amr Saeed
   
List of Contents
Content
Page
List of abbreviations
i
List of figures
ii
Introduction
١
Aim of work
٣
Anatomy and nerve supply of the knee joint
٤
General anesthesia for arthroscopic knee surgery
١٩
Regional anesthesia for arthroscopic knee surgery
٢٧
Postoperative considerations for arthroscopic knee
Surgery
٧٠
Summary
٨٦
References
٨٨
Arabic summary
List of Abbreviations
ACL: Anterior Cruciate Ligament
ASIS: Anterior Superior Iliac Spine
CI: Cardiac Index
CSF: Cerebrospinal Fluid
DVT: Deep Venous Thrombosis
LCL: Lateral Collateral Ligament
MAC: Monitored Anesthesia Care
MAP: Mean Arterial Blood Pressure
MCL: Medial Collateral Ligament
NSAID: Non Steroidal Anti Inflammatory Drugs
PACU: Post Anesthesia Care Unit
PCA: Patient Controlled Analgesia
PCL: Posterior Cruciate Ligament
PDPH: Post Dural Puncture Headache
PE: Pulmonary Embolism
PONV: Postoperative Nausea and Vomiting
PSIS: Posterior Superior Iliac Spine
SVRI: Systemic Vascular Resistance Index
TIVA: Total Intravenous Anesthesia
i
List of Figures
Figure No.
Page
Figure ١:
Coronal section of the knee
٤
Figure ٢:
Lateral view of the knee joint
٦
Figure ٣:
Posterior view of the knee joint
٧
Figure ٤:
٩
The patellar ligament
Figure ٥:
١٠
Left knee joint showing the interior ligaments
Figure ٦:
The medial collateral ligament
١١
Figure ٧:
The oblique popliteal ligament
١٢
Figure ٨:
Medial view of the knee joint showing the
Figure ٩:
anterior cruciate ligament
١٣
The vascular supply of the knee joint
١٥
Figure ١٠: The anterior and the posterior view of the knee
innervations
١٧
Figure ١١: The anterior and the posterior view of the leg
innervations including the knee joint
١٧
Figure ١٢: Sensory supply of the human body
١٨
Figure ١٣: The lateral decubtius postion
٣١
Figure ١٤: The seated postion
٣٢
ii
Figure١٥:
The injection of the local anesthesia
Figure ١٦: The introduction of the spinal needle and
٣٤
٣٤
puncture of the subarachnoid space
Figure ١٧: The subarachnoid position of the needle
٣٥
Figure ١٨: Loss of resistance technique
٣٨
Figure ١٩: Nerve stimulator with ١٠cm stimuplex
٤١
insulated neede
Figure ٢٠: The femoral nerve lateral to the femoral
artery and below the inguinal ligament
٤٢
Figure ٢١: Femoral nerve block
٤٣
Figure ٢٢: Injection of the femoral nerve
٤٤
Figure ٢٣: The ultrasound-guided femoral nerve block
٤٥
Figure ٢٤: The labat’s approach of the sciatic nerve block
٤٨
Figure ٢٥: The injection needle introduced perpendicular
to the skin surface
٤٩
Figure ٢٦: Parasacral approach of sciatic nerve block
٥٠
Figure ٢٧: The Ultrasound-guided parasacral approach
of the sciatic nerve block
٥١
Figure ٢٨: Gluteal and subgluteal approach of the
sciatic nerve block
٥٢
iii
Figure ٢٩: Anterior approach of the sciatic nerve block
٥٣
Figure ٣٠: The ultrasound- guided anterior approach
of the sciatic nerve block
٥٥
Figure ٣١: Lateral popliteal approach of the sciatic
nerve block
٥٦
Figure ٣٢: The ultrasound-guided popliteal approach
of the sciatic nerve block
٥٧
Figure ٣٣: Posterior popliteal approach of the
sciatic nerve block
٥٨
Figure ٣٤: Lumbar plexus nerve block
٦٠
Figure ٣٥: The landmarks for the obturator nerve block
٦٢
Figure ٣٦: Cranial injection of the inguinal femoral
paravascular block
٦٥
Figure ٣٧: Local infiltration of the knee joint
٦٧
Figure ٣٨:
٦٧
Suprapatelar infiltration
Figure ٣٩: Infiltration of the anterior portals
٦٨
Figure ٤٠: Postoperative vomiting after isoflurane,
enflurane, sevoflurane, and propofol
Figure ٤١: Incidence of early vomiting (٠-٢ hr after
maintenance with volatile anesthetics or
iv
٨٠
propofol
٨١
v
Introduction
The optimal anesthetic technique in knee arthroscopic surgeries
would provide excellent operating conditions, rapid recovery, no
postoperative side effects, high degree of patient satisfaction and
early home discharge. In addition, it should improve the quality of
care and decrease the costs of anesthetic services. General
anesthesia, regional anesthesia and local anesthesia are all
commonly used for arthroscopic knee surgeries; however,
opinions differ as to the best anesthetic technique for these
surgical procedures (White, ٢٠٠١).
General anesthesia has been the standard anesthetic utilized in
knee surgery and the benchmark by which all other techniques are
measured. Although general anesthesia is remarkably safe,
effective and often the best choice in many clinical situations,
there are several disadvantages to employing it in the ambulatory
surgery environment. For instance, post-operative nausea and
vomiting (PONV) is a recognized complication of general
anesthesia. When compared to regional blocks, PONV occurs
significantly more frequently in general anesthesia patients. Postoperative pain is another frequent complication (Buckenmaier,
٢٠٠٢).
Regional anesthetic techniques treat surgical pain by attenuating
the transmission of painful stimuli from the surgical site to the
central nervous system. Clinical studies have also demonstrated
improved recovery and rehabilitation following knee surgery with
regional anesthesia. Other advantages of regional anesthesia
compared to general anesthesia include reduced surgical stress
response, improved immune functions and respiratory dynamics
١
and reduced thromboembolic complications (Greengrass, ٢٠٠٠;
Klein et al., ٢٠٠١).
Local intra-articular knee anesthesia is an ideal technique for
knee arthroscopy because it is simple and bears low levels of
morbidity. It reduces pain and analgesic consumption allowing
early rehabilitation with shorter hospital stay and reduction of
costs. However, there are situations in which it is preferable to
use general or regional anesthesia, as in the case of children,
patients with psychiatric disorders, non-cooperative or
apprehensive patients and more extensive forms of surgery
(Regidor et al., ٢٠٠٧).
٢
Aim of the Work
The aim of this work is to review current literature on anesthetic
techniques for knee arthroscopic surgeries and to outline
advantages, disadvantages and clinical application of each
technique.
٣
Anatomy and Nerve Supply of the Knee Joint
The knee joint is our largest and most superficial joint (Fig.١). It
is primarily a hinge type of synovial joint, allowing flexion and
extension; however, the hinge movements are combined with
gliding and rolling and with rotation about a vertical axis.
Although the knee joint is well constructed, its function is
commonly impaired when it is hyperextended (e.g., in body
contact sports, such as ice hockey). Because the knee joint is
involved in weightbearing, it has an efficient 'locking' mechanism
to reduce the amount of muscle energy required to keep the joint
extended when standing (Agur et al., ٢٠١٠).
Fig.١ Coronal section of the knee joint. From Agur et al.
(٢٠١٠).
٤
The Articular bodies :
The articular bodies of the femur are its lateral and medial
condyles. These diverge slightly distally and posteriorly, with the
lateral condyle being wider in front than at the back while the
medial condyle is of more constant width. The radius of the
condyles' curvature in the sagittal plane becomes smaller toward
the back. This diminishing radius produces a series of involute
midpoints. The resulting series of transverse axes permit the
sliding and rolling motion in the flexing knee while ensuring the
collateral ligaments are sufficiently lax to permit the rotation
associated with the curvature of the medial condyle about a
vertical axis (Platzer, ٢٠٠٤).
The pair of tibial condyles are separated by the intercondylar
eminence composed of a lateral and a medial tubercle. The patella
is inserted into the thin anterior wall of the joint capsule. On its
posterior surface is a lateral and a medial articular surface, both of
which communicate with the patellar surface which unites the two
femoral condyles on the anterior side of the bone's distal end
(Platzer, ٢٠٠٤).
The Articular Capsule:
The articular capsule has a synovial and a fibrous membrane
separated by fatty deposits. The two layers are adjacent on each
side, but they part company centrally to accommodate
intercondylar and infrapatellar structures that are intracapsular
that is inside the fibrous layer but extra-articular that is excluded
from the articular cavity by synovial membrane (Drake et al.,
٢٠٠٧).
Anteriorly, the synovial membrane is attached on the margin of
the cartilage both on the femur and the tibia, but on the femur, the
٥
suprapatellar bursa (Fig.٢) or recess extends the joint space
proximally. The articularis genu pulls the synovial membrane of
the suprapatellar bursa superiorly during extension of the knee so
that it will not be caught between the patella and femur within the
knee joint. Behind, the synovial membrane is attached to the
margins of the two femoral condyles which produce two
extensions similar to the anterior recess. Between these two
extensions, the synovial membrane passes in front of the two
cruciate ligaments at the center of the joint, thus forming a pocket
(Agur and Dalley, ٢٠٠٩).
Fig.٢ lateral view of the knee joint. This figure shows the
suprapatellar bursa. From Agur and Dalley (٢٠٠٩).
٦