Anesthesia and Orthopaedic Surgery. By André P. Boezaart, M.B., Ch.B., F.F.A.(C.M.S.A.), M.Med.(Anaesth.), Ph.D. New York, McGraw Hill, 2006. Pages: 453. Price: $159.00.
“… Regional anesthesia is here to stay …”
This was the prediction of William J. Mayo (Professor, Department of Surgery, Mayo Clinic, Rochester, Minnesota; 1861–1939) when he wrote the Forward to Gaston Labat’s (Professor, Department of Anesthesia, New York University and Bellevue Hospitals, New York, New York; 1876–1934) book, Regional Anesthesia: Its Technic and Clinical Application in 1922. Now, more than 80 yr later, this quotation has taken on new meaning in the field of orthopedic anesthesia. The subspecialty of orthopedic anesthesia has seen tremendous growth and interest during the past decade. This has been driven by multiple factors, including an aging patient population, improvements in the application of regional anesthetic techniques, a greater demand for joint replacement surgery, and advancements in endoscopic techniques, biocompatible materials, imaging equipment, and computer-guided technologies. In fact, the American Academy of Orthopedic Surgeons and the National Center for Healthcare Statistics estimate that more than 8.2 million orthopedic procedures will be performed in 2007—nearly 30% of all major surgical interventions. Therefore, the release of a new comprehensive text addressing the critical issues of the subspecialty could not be more timely.
The text is divided into four major sections: General Principles (6 chapters), Operative Orthopaedic Procedures (11 chapters), Regional Anesthesia for Orthopaedic Surgery (14 chapters), and Miscellaneous Topics (3 chapters). The first section (Part I: General Principles) begins with an overview of “Orthopaedic Anesthesia as a Subspecialty of Anesthesia.” This is followed by an extensive review of “Homeostasis in Massive Multiple Trauma.” The chapter provides a detailed discussion on the epidemiology and pathophysiologic response to trauma, including an overview of the complex cellular and neuroendocrine response to trauma and the effect of systemic injury on individual organ systems. The chapter concludes by reviewing the basic principles of trauma management, including resuscitation, monitoring, fluid management, vasoactive therapy, and postoperative intensive care unit support. The remaining segments of Part I focus on the “Prevention of Infection in Orthopaedic Surgery” and “Thromboprophylaxis in Orthopaedic Surgery.” Although the discussion on infection and the prevention of infectious complications is quite superficial, the authors do a superb job of reviewing the incidence and impact of venous thromboembolism in orthopedic surgery, the pharmacology of antithrombotic medications, and recommended treatment options for thromboprophylaxis. More importantly, an extensive discussion nicely outlines the impact of anesthesia on venous thromboembolism, and the implications of perioperative thromboprophylaxis on the selection of anesthetic technique and perioperative analgesia.
The second section of the textbook (Part II: Operative Orthopaedic Procedures) is what makes this reference a valuable addition to your library. The chapters are written by orthopedic surgeons in collaboration with anesthesiologists to provide a unique and insightful view into the world of the orthopedist. Most experts would agree that optimal outcomes in orthopedic surgery rely heavily on the anesthesiologist’s understanding of the technical aspects of the procedure—including intraoperative positioning issues, potential perioperative complications, and postoperative rehabilitative goals and requirements. This section provides those insights. The chapters are organized by joint or anatomical region, and address basic anatomic considerations (including the biomechanics of most joints), common surgical procedures, anesthetic considerations, intraoperative and postoperative pain management schemes, postoperative protocols, and common perioperative complications. The chapters also emphasize how surgeons, anesthesiologists, physical therapists, and nurses must work as a coordinated team to optimize patient care. This is accomplished by understanding the roles and responsibilities of each discipline. The remaining segments of Part II focus on “Common Orthopaedic Fractures,” as well as the etiology, pathophysiology, diagnosis, and treatment of compartment syndrome. The section concludes with a comprehensive description of common “Sports Injuries to the Shoulder, Knee, and Ankle.” A potential criticism of Part II is the absence of evidence-based recommendations for many of the suggested anesthetic and perioperative analgesic techniques. Furthermore, all chapters were coauthored by the editor, which may introduce a personal and/or institutional bias for the recommended modalities of anesthetic management.
The third section of the text (Part III: Regional Anesthesia for Orthopaedic Surgery) covers the vast array of regional anesthetic techniques available for orthopedic surgery. It is yet another highlight of the book that focuses on continuous peripheral nerve blockade, neuraxial anesthesia and analgesia, and the ambulatory treatment of pain. Each chapter follows a consistent outline, describing relevant gross anatomy, functional neuroanatomy (including expected motor responses from nerve stimulation), and applied surface anatomy; patient selection and positioning; block technique (single-injection and continuous catheter applications); local anesthetic selection; and potential problems and complications. The section also includes comprehensive and informative chapters on “Commonly Used Drugs and Equipment,”“Electrical Nerve Stimulation,”“Continuous Peripheral Nerve Blocks,” and “The Use of Ultrasound for Peripheral Nerve Blocks.” In general, the chapters of this section are well written, well referenced, and compiled by recognized experts in the field. Finally, the textbook concludes with a spattering of miscellaneous topics (Part IV: Miscellaneous Topics), including nerve injury, bone cement, and battlefield orthopedic anesthesia.
With regard to format, there are a number of features that are particularly appealing. For example, each chapter possesses a structured outline that is reliably consistent throughout the text. The authors—experienced and novice alike—should be commended for their excellent writing style, and the publisher should be congratulated on a thorough and comprehensive index that makes navigating the text a simple task. Illustrations include both black-and-white line drawings and colorful cross-sectional and three-dimensional anatomical depictions of relevant musculoskeletal and neurovascular anatomy (artwork by Mary K. Bryson). In most cases, the illustrations do a nice job of emphasizing those structures most relevant to the orthopedic anesthesiologist, including needle insertion sites, trajectory, and depth of insertion. Finally, Dr. Boezaart’s authorship of many of the chapters gives the book a stylistic consistency that greatly enhances its readability. However, it also brings a degree of personal bias that is unavoidable throughout much of the text. This is not a criticism of the book, but a limitation of any reference that is heavily influenced by a few select authors. Importantly, these imperfections are few, and pale in comparison to the clear and obvious strengths of the text. So, whether you are a casual practitioner of orthopedic anesthesia or an expert specializing in this expansive subspecialty, Anesthesia and Orthopaedic Surgery deserves a spot in your reference library.
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