Si Chen,Lijian Pei

Department of Anesthesiology,Peking Union Medical College Hospital,Chinese Academy of Medical Sciences &Peking Union Medical College,Beijing 100730,China

Key words:anesthesia;advanced age;periprosthetic fracture

Abstract A 98-year-old male patient with history of hemiarthroplasty suffered periprosthetic fracture of right femoral shaft and developed acute coronary event in three days after hospitalization.Femoral nerve and lateral femoral cutaneous nerve blocks combined with general anesthesia were implemented for the internal fixation surgery.The recovery was uneventful after discharge.In this case report,we discussed the main considerations of anesthesia specifically for this complicated case.

THE incidence of periprosthetic fractures after primary knee and hip arthroplasty is around 2.5% or even higher.1Fractures of the femur,especially after arthroplasty,are the most common complications in geriatric people due to poor bone quality and periprosthetic bone loss.Here we present a case of 98-year-old male patient who fell down,had periprosthetic fracture and developed acute coronary event three days later,and recovered after successful internal fixation surgery.Regarding the surgery characteristics and the patient's complex status,the main anesthesia considerations are discussed specifically in this case report.

CASE DESCRIPTION

A 98-year-old male who had received hemiarthroplasty for right femoral neck fracture four years ago was diagnosed with a right periprosthetic femoral shaft fracture after a fall.Mold fixation was attempted but was aborted due to intolerable pain,swelling of lower extremity and decubitus ulcer formation.Three days after admission,the patient developed acute myocardial ischemia.Creatine kinase isoenzymes(CK-MB) mass reached 13.7 μg/L.The patient was diagnosed with the non-ST segment elevation myocardial infarction(NSTEMI).

He was treated conservatively,with eventual consequence that CK-MB decreased to 2.7 μg/L.Transthoracic echocardiography showed no motion abnormalities of cardiac segmental wall,and left ventricular ejection fraction (LVEF) was 64%.Open reduction and internal fixation were planned for the operative therapy of this patient.Prior to the surgery,the patient exhibited a left bundle branch block and occasional premature ventricular contractions on ECG,but was otherwise stable.

Physical exam showed his body temperature was 37.2°C,heart rate 80-95 beats per minute,respiratory rate 20 per minute,blood pressure 110-130 mmHg/50-65 mmHg.Laboratory exam showed mildly prolonged prothrombin time(PT),activated partial thromboplastin time (APTT),normal platelet count,and hemoglobin of 99 g/L.Ultrasound-guided femoral nerve and lateral femoral cutaneous nerve blocks were accomplished,and after arterial line placement he was induced and intubated for close hemodynamic monitoring.Anesthesia was maintained with sevoflurane 1.5%and air-oxygen mixture,with the Fraction of inspiration O2(Fi O2) of 0.5.Surgery lasted two hours,with a blood loss of 800 ml,intraoperative autologous blood transfusion of 236 ml from Cell Saver 5+,and allogeneic blood transfusion of 4U.The hemoglobin level was maintained around 100 g/L during the operation.

The patient was transported to ICU intubated after surgery.He was weaned from the ventilator successfully on the third day of ICU care and then transferred to the department of Gerontology.Advanced treatments,including anti-infection,volume management,intensive care,nutritional support and functional exercise,were effectively applied.On the 53rd day after the operation,he was capable to ambulate with help and thus was discharged from the hospital.

DISCUSSION

Periprosthetic femoral fracture is one of the most common fracture types in geriatric patients.2It is associated with a high mortality rate early after fracture and significant functional disability.Surgery should always be considered as an option,even when the anesthetic risk is high,such as in this patient who presented acute coronary syndrome.3Conservative therapy usually involves prolonged immobilization,predisposing patients to pneumonia,thromboembolic events,decubitus ulcer formation,as well as nonunion fracture and severe pain.Currently,conservative therapy has been considered obsolete,especially in elderly patients.1

For patients with femoral shaft fracture,the perioperative management often aims to minimize the anesthetic risk,especially through appropriate transfusion management and early mobilization.For the presented patient,the critical problems lie in the characteristics of periprosthetic fracture.First of all,patients with periprosthetic fractures are often in advanced age,such as the extreme advanced age in this case,accompanied with serious complications.Secondly,the surgery of periprosthetic femoral facture is relatively difficult in condition of massive bleeding,which brings significant surgical trauma and stress response.Therefore,this case is not simply a fracture surgery for an elderly patient.How to judiciously choose anesthesia method became the key point of considerations for this patient.

General anesthesia and regional anesthesia are useful for geriatric patients in non-cardiac surgery.4Although evidence has shown that epidural anesthesia is associated with superior perioperative outcomes on major lumber surgery in elderly patients,5there is little evidence and no conclusion for patients over 90 years old to receive periprosthetic fracture surgery.Intrathecal anesthesia alone would be sufficient for the surgery;however,it may not provide adequate oxygen supply and leaves the air way with no protection.We believe that adequate oxygen supply is extremely important for the patient.Also,for patients at such an advanced age6and lack of oral hygiene,7the incidence and prevalence of aspiration pneumonia increases remarkably,which is mainly related to alterations in oropharyngeal and gastro-esophageal motility as well as colonization by respiratory pathogens.For this reason,we believe that endotracheal intubation is important during the operation and in a short period of postoperative time,instead of using supraglottic device,for example,laryngeal mask airway.Although nerve block alone would not be a sufficient anesthesia for this procedure,regional anesthesia is still a valuable technique,8,9given the patient's age,comorbidities and potential postoperative complications.Regional anesthesia combined with general anesthesia provides better pain control than general anesthesia alone,as evidenced by reduced opioid consumption.Therefore,femoral nerve and lateral femoral cutaneous nerve blocks combined with general anesthesia became the anesthesia method we implemented for this patient.The relieved pain and uneventful recovery had confirmed the effectiveness and reasonability of the anesthetic method for this case.

As China is becoming an aging society,patients who receive arthroplasty live a longer life and have increased opportunities of periprosthetic fracture.As they age,their health conditions become more fragile,which predisposes them to complications during anesthesia.The overall therapeutic approaches in perioperative care should be jointly determined by a multidisciplinary team including orthopedist,geriatrician,anesthesiologist,and ICU physician.

Conflict of interest statement

The authors declared no conflict of interests.