Excision of the radial head

What the Anesthesiologist Should Know before the Operative Procedure

Radial head excision is performed only in stable elbow with laterally based elbow pain as a result of forearm rotation and/or axial loading. Radial head excision is not performed in elbows with pre-existing instability, especially in fracture dislocation, because of poor outcome result. The anesthesiologist should know that this surgery may be changed perioperatively into elbow prosthesis/replacement. Indications for this type of surgery include mainly arthritis, (posttraumatic) arthrosis, and acute trauma (isolated comminuted radial head fracture).

1. What is the urgency of the surgery?

There is no urgency for this type of surgery except in case of open fracture.

Emergent: There is neither emergency nor urgency for this type of surgery.

Urgent: In case of open fracture, the surgery should be performed as soon as possible in order to reduce the risk of infection.

Elective: In 99%, this type of surgery is elective.

2. Preoperative evaluation

The main issue here is the frequent occurrence of rheumatoid arthritis (RA). Patients with RA need to be extensively investigated since many articular and extra-articular problems can have implications for anesthesia that have to be considered. Special consideration should be made in case of arthrosis that will involve elderly patients and problems associated with aging. Trauma occurs mainly in young people, usually with few comorbidities.

Due to the absence of emergency, any medically unstable condition can be corrected in due time including lung, heart, kidney function, etc. Delaying surgery does not affect the surgical outcome. Patient stabilization, if necessary, is more important.

3. What are the implications of co-existing disease on perioperative care?

In 99% of the cases, this will be an elective surgery. This means that the anesthesiologist will have time to make a complete evaluation of the patient condition in order to reduce the perioperative risk.

Special considerations are especially important for patient with RA. RA is a systemic chronic inflammatory disease affecting up to 3% of women and men in the Western world. Approximately 70% of cases are associated with the HLA-DR4 subtype, and 80% of patients are positive for rheumatoid factors.

b. Cardiovascular system

The cardiovascular system can be affected by a pericardial effusion (pericarditis and cardiac tamponade); myocarditis due to deposit of amyloidosis and granulomatous disease, endocarditis, peripheral vasculitis with Raynaud’s phenomenon, increased atherosclerosis, and coronary heart disease. The possibility of aortic and mitral valve disease should be checked. The presence of any of these problems should be evaluated and managed accordingly.

c. Pulmonary

The respiratory system is mainly affected in RA by restrictive defect due to fibrosing alveolitis, interstitial fibrosis, residual reduced chest wall compliance and pleural effusions.

d. Renal-GI:

Subclinical renal dysfunction is common in patients with RA. The renal function is mainly affected by the toxic effects of the drug used for the treatment of the disease (gold, penicillamine, nonsteroidal anti-inflammatory drugs [NSAIDs]).

Clinical hepatomegaly occurs in approximately 10%. It consists of nonspecific fatty change. Hepatic enlargement may also occur in association with splenomegaly due to Felty’s syndrome.

e. Neurologic:

These patients may suffer from peripheral neuropathy and autonomic dysfunction. These signs and symptoms should be investigated specifically and documented preoperatively.

f. Endocrine:

Endocrine/hematology

These patients may suffer from peripheral neuropathy and autonomic dysfunction. These signs and symptoms should be investigated specifically and documented preoperatively.

Features to be carefully evaluated

The atlantoaxial joint is commonly affected in RA patients because of attenuation of the transverse ligament and erosion of the odontoid peg. This is responsible for atlanto-axial instability in about 20% to 30% of these patients. This problem should be documented before anesthesia.

Involvement of the cricoarytenoid joints may be the cause of dyspnea, stridor, hoarseness, and, from time to time, upper airways obstruction. The involvement of temporomandibular joint may cause limitation of mouth opening.

4. What are the patient's medications and how should they be managed in the perioperative period?

The majority of these patients are managed with NSAIDs, steroids, and anti-arthritic drugs (methotrexate, chloroquine, azathioprine). These drugs should be continued until surgery and should be resumed as soon as possible after surgery.

h. Are there medications commonly seen in patients undergoing this procedure and for which should there be greater concern?

NSAIDs may be responsible for gastric bleeding and ulceration, nephrotoxicity, fluid retention, increased perioperative bleeding, hypertension, and heart failure.
Chronic use of steroids is responsible for osteoporosis, hypertension, electrolyte imbalance, diabetes, obesities, peptic ulcer disease, and fragile skin.
Methotrexate is associated with pulmonary toxicity and hepatic cirrhosis.
Sulfasalazine can cause neutropenia, thrombocytopenia, aplastic anemia, and fibrosing alveolitis.
Azathioprine causes bone marrow suppression and cholestatic hepatitis.
Anticytokine drugs are responsible for flu-like symptoms, gastrointestinal dysfunction, blood disorder, and demyelinating disorder of the central nervous system (CNS).
In case of general anesthesia, gastric protection is advisable because of steroid intake.

i. What should be recommended with regard to continuation of medications taken chronically?

Most of the drugs taken chronically must be continued until surgery. Especially for concerns over surgical bleeding, aspirin should be stopped 5 to 7 days before surgery. Antiplatelet drugs should be discontinued 5 days before surgery. If these drugs are administered because of an intracoronary stent, consultation with the patient’s cardiologist is warranted to develop an appropriate perioperative strategy. If for any reason this drug should be continued until surgery, the performance of an axillary block is not contraindicated.

j. How to modify care for patients with known allergies

In case of known allergies, implicated drugs should be avoided.

k. Latex allergy- If the patient has a sensitivity to latex (e.g., rash from gloves, underwear, etc.) versus anaphylactic reaction, prepare the operating room with latex-free products.

In case of antibiotic allergy, mainly penicillin, a suitable alternative should be discussed with the surgeon.

m. Does the patient have a history of allergy to anesthesia?

Malignant Hyperthermia

Trigger drugs such as succinylcholine and inhalation agents should be avoided.

A total intravenous anesthesia (TIVA) technique with propofol should be used. Regional anesthesia is the first choice in this setting.

In case of local anesthetic allergy, regional technique should be avoided. Cross-sensitivity between amino-amides local anesthetics has been reported, but not between amino-amides and ester agents. General anesthesia using TIVA is preferred.

5. What laboratory tests should be obtained and has everything been reviewed?

Routine laboratory tests according to the age of the patient should be obtained. More specific tests should be ordered according to the specific signs and symptoms disclosed during the preoperative examination.

Intraoperative Management: What are the options for anesthetic management and how to determine the best technique?

For this type of surgery, regional anesthesia is the gold standard. This technique has the advantage of avoiding airways manipulation, intubation, and ventilatory changes associated with general anesthesia. Regional techniques also provide better postoperative analgesia and a better control of the stress reaction compared to general anesthesia. Special concerns of patients positioning is mandatory to avoid positioning injury.

Regional anesthesia

In this surgical context, three approaches are recommended: the supraclavicular, the infraclavicular, or axillary blocks.

The supraclavicular approach has the risk of pneumothorax and does not offer the best condition for catheter placement.
The infraclavicular technique according to the modified technique of Raj prevents the occurrence of pneumothorax and offers the best condition for catheter placement.
The axillary approach has the disadvantage of necessitating several injections and the success of perineural catheter is lower compared to infraclavicular technique.

Neuraxial block are not indicated for this type of surgery.

The use of sedation is recommended due to the positioning issues, which may cause pain for the patient. Moreover, positioning should be carefully performed since the steroid may increase the skin fragility and may be responsible for excessive bruising. Fortunately for an uncomplicated radial head excision, duration of surgery is short.

General anesthesia

General anesthesia should be avoided whenever possible in these patients for the above mentioned reasons (difficulty for intubation, reduced respiratory capacity). If necessary, then careful airway management (potentially with a fiberoptic intubation) might be necessary. Restrictive lung disease may require gentler ventilation and careful observation of airway pressures.

Monitored anesthesia care:

In monitored anesthesia, the same precautions mentioned above should be performed. However, the procedure is too invasive to be done under MAC alone.

6. What is the author's preferred method of anesthesia technique and why?

For this type of surgery the author’s preferred method of anesthesia is continuous infraclavicular anesthesia/analgesia using the modified Raj technique because it provides ideal condition for the catheter placement and the possibility of pneumothorax is very unlikely. Sedation is recommended and the author’s preference for this block is low-dose administration of both propofol and remifentanil.

In our department, cefuroxime is the first-choice prophylactic antibiotic.
A lateral Kocher-type approach is most frequently used for the operative treatment of radial head pathologies.
This type of surgery is usually short; the bleeding is minimal but one has to take into account that patients with RA have a tendency to bleed more. Some surgeons will use a tourniquet; some will not. The anesthesiologist should be prepared for longer surgery in case of elbow instability (acute complex dislocation with radial head fracture) because this problem might switch this surgery into a complex reconstructive procedure including open reduction and internal fixation and radial head prosthesis. Due to the usually short duration of the procedure and the minimal bleeding, the surgery per se does not create major physiological fluctuations for the patient.
The most common complication is postoperative (partial) elbow stiffness. Perioperative complications are rare and include infections, radialis and posterior interosseous nerve paresis, and complication due to the application of the tourniquet. The use of regional technique will reduce the incidence of cardiac and pulmonary complications.

a. Neurologic:

The possibility of post block neuropathy has been reported and its incidence is very low (approximately 0.2%-0.4%).

b. If the patient is intubated, are there any special criteria for extubation?

In case of general anesthesia, the restrictive component of the lung function should be taken into account to achieve an uneventful extubation. This implies that the action of the muscle relaxant and anesthetic drugs should have completely worn off.

c. Postoperative management

This is a moderately painful surgery and the application of a continuous infusion of local anesthetic (LA) is warranted for 48 hours. For outpatients, the use of an elastomeric pump is recommended. Thromboprophylaxis is not necessary since this patient can be immediately mobilized. Acetaminophen and NSAIDs are a part of a multimodal postoperative pain treatment. In case of coagulation disturbance, the axillary block is a first choice. The occurrence of postoperative delirium in elderly patients is possible. Its incidence may be reduced if regional anesthesia is performed, but it appears nevertheless unavoidable to some extent in the elderly with the stress of surgery.

What's the Evidence?

Gendi, NST. “Synovectomy of the elbow and radial head excision in rheumatoid arthritis”. J Bone Joint Surg Br. vol. 79-B. 1997. pp. 918-23.

Connor, PM, Lundeen, GA. “The rheumatoid elbow: current concepts and controversies”. Curr Opin Orthop. vol. 14. 2003. pp. 302-6. (Two articles with a good overview of the surgical issues.)

Lisowska, B. “Anaesthesiological problems in patients with rheumatoid arthritis undergoing orthopaedic surgeries”. Clin Rheumatol. vol. 27. 2008. pp. 553-6.

Skues, MA, Welchew, EA. “Anaesthesia and rheumatoid arthritis”. Anaesthesia. vol. 48. 1993. pp. 989-97.

Fombon, FN, Tempson, JP. “Anaesthesia for the adult patient with rheumatoid arthritis”. Contin Edu Anaesth Crit Care Pain. vol. 6. 2006. pp. 235-9. (Three articles with a complete review that deals with anesthetic issues and RA.)

Kremer, JM. “Rational use of new and existing disease-modifying agents in rheumatoid arthritis”. Ann Intern Med. vol. 134. 2001. pp. 695-706. (A good overview of the impact of the drugs used for RA.)

Strachan, JCH, Ellis, BW. “Vulnerability of the posterior interosseous nerve during radial head resection”. J Bone Joint Surg Br. vol. 53-B. 1971. pp. 320-3. (This article describes some complications associated with surgery.)

Borgeat, A. “Evaluation of the infraclavicular block via a modified approach of Raj's technique”. Anesth Analg. vol. 93. 2001. pp. 436-41.

Dullenkopf, A. “Diaphragmatic excursion and ventilatory function after the modified Raj technique of the infraclavicular plexus block”. Reg Anesth Pain Med. vol. 29. 2004. pp. 110-14. (Two articles that describe the feasibility and the use of this approach.)

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