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The two most frequently performed knee surgeries are arthroscopy and total or partial joint replacement.
Arthroscopy has revolutionized surgery of many joints, including the hip, knee, shoulder, ankle, elbow, and wrist. Joint arthroscopies are usually performed as outpatient procedures. Although the typical patient undergoing knee arthroscopy is often thought of as being a healthy young athlete, knee arthroscopies are frequently performed in elderly patients with multiple medical problems.
A bloodless field greatly facilitates arthroscopic sur-gery. Fortunately, knee surgery lends itself to the use of a pneumatic tourniquet. The surgery is per-formed as an outpatient procedure with the patient in a supine position under general anesthesia or neuraxial anesthesia. Alternative anesthetic tech-niques include peripheral nerve blocks, periarticu-lar injections, or intraarticular injections employing local anesthetic solutions with or without adjuvants combined with intravenous sedation.
Comparing neuraxial anesthesia techniques, success and patient satisfaction appear to be equal between epidural and spinal anesthesia. However, for ambulatory surgery, time to discharge following neuraxial anesthesia may be prolonged compared with general anesthesia.
Successful outpatient recovery depends on early ambulation, adequate pain relief, and minimal nau-sea and vomiting. Techniques that avoid large doses of systemic opioids have obvious appeal. Intraarticular local anesthetics (bupivacaine or
ropi-vacaine) usually provide satisfactory analgesia for several hours postoperatively. Adjuvants such as opioids, clonidine, ketorolac, epinephrine,and neostigmine when added to local anesthetic solutions for intraarticular injection have been used in various combinations to extend the duration of analgesia. Other multimodal pain management strategies include systemic NSAIDs, gabapentin, and single or continuous peripheral nerve blocks for arthroscopic ligament reconstruction.
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