How We Use Local Blocks in Office-Based Orthopedic Surgery

Jack M. Bert, MD

We currently do interscalene blocks for shoulder surgery, axillary blocks for upper extremity surgery, knee blocks for all arthroscopies, and ankle blocks for ankle and foot surgery. Here are the details on each of these blocks and how we ensure that they are effective:

Interscalene blocks:
To date, we have performed more than 950 interscalene blocks for open and arthroscopic shoulder procedures, without having to use general anesthesia. These blocks last an average of four to five hours postoperatively. To help the patient relax, we administer Monitored Anesthesia Control (MAC), consisting of Versed and Diprovan. Several of our patients actually watch the television monitor while we¹re doing their procedures.
Axillary blocks:
Axillary blocks, which we use for most procedures distal to the shoulder, require almost no MAC assist during the operative procedure. The recovery time is extremely rapid and the duration of the block is approximately 4 hours.
Knee blocks:
We have performed more than 2,250 knee blocks for knee arthroscopy. To do a knee block, we inject 50 ccs of marcaine with 0.5% epinephrine into the knee joint and arthroscopic portal sites 30 minutes prior to the surgical procedure. It is very important to inject the local anesthesia at least 30 minutes prior to the time of surgery, simply because it takes that long for the anesthetic to infiltrate the synovium and joint surfaces. By using epinephrine in the marcaine, we avoid having to use a tourniquet when performing the surgery.

We proved that epinephrine helps avoid the need for a tourniquet in a study that we performed in 1997. We did 400 cases without tourniquet control using marcaine and epinephrine and did another 400 under general anesthesia using marcaine without epinephrine and with tourniquet control. We documented the visualization of the procedure with serial intraoperative pictures. The patients that had the procedure performed with the epinephrine and marcaine block statistically had clearer intraoperative images than the group using tourniquet control without epinephrine. The epinephrine constricted the blood vessels so that there was no bleeding.

Even though our local knee block technique results in a thoroughly anesthetized joint, we often also use MAC assist to help relieve the pain associated with the stress placed on the thigh by the knee holder in a tight joint when we are attempting to resect the posterior horn of the meniscus.

Ankle blocks:
We use ankle blocks for ankle and bunion surgery. This block involves infiltrating the nerves at the ankle joint anteriorly, laterally, and medially with marcaine without epinephrine (we do not use epinephrine to avoid constricting major blood vessels to the foot). It is helpful to inject the anesthetic at least 15 to 30 minutes prior to the onset of surgery for the block to have maximal effect. We have also been able to perform ankle procedures such as a lateral ligamentous reconstruction and open reduction of lateral and bimalleolar fractures using this technique with MAC assist.

The time required for an average surgical procedure in our office breaks down as follows: 72 minutes for pre-op, 41 minutes for the procedure, and 38 minutes for post-op care. Patients who have interscalene, axillary, and knee blocks literally walk into and out of the operating room pre- and post-operatively with nursing assistance.

We have only had one complication in five years. This occurred when our board certified anesthesiologist (whom we use exclusively) accidentally injected local anesthesia into the thecal sac while performing an interscalene block. The patient experienced incomplete respiratory paralysis requiring transfer to the hospital via ambulance (fortunately, we did have an emergency transfer agreement, which is required by most states for ASCs). The patient had an uneventful recovery and rescheduled his rotator cuff surgery the following week. His surgery went well and he has had no residual complaints.

In the vast majority of cases, local blocks have helped us produce excellent results. We believe that they are the reason that our patient satisfaction rate, as measured by postoperative callbacks and surveys, has been over 98 percent. When performed by an experienced anesthesiologist, local blocks are safe, effective, reliable, and should be the anesthesia of choice for office-based orthopedic surgery.