What the Anesthesiologist Should Know before the Operative Procedure

  • Anatomy:

    Musculoskeletal: The quadriceps muscle is composed of four muscle groups – rectus femoris, vastus medialis, vastus lateralis, and vastus intermedius. The quadriceps tendon is a trilaminar structure formed by the coalescence of all four muscle tendons just proximal to the suprapatellar margin. The rectus femoris becomes tendinous approximately 3-5cm proximal to the patella and forms the most superficial layer to the quadriceps tendon. The middle layer is comprised of vastus medialis and lateralis, which respectively become tendinous just millimeters and 3cm proximal to their insertions into the patella. The deep layer is composed of the vastus intermedius.

    Neurovascular: The quadriceps is innervated by the femoral nerve and receives arterial contributions from the ascending, descending and transverse branches of the lateral femoral circumflex artery, descending geniculate artery, and medial and lateral superior geniculate arteries.

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    Biomechanics: The quadriceps muscle and tendon function as part of the knee extensor mechanism, which also includes medial and lateral retinaculum, patellofemoral and patellotibial ligaments, patellar tendon and tibial tubercle. The superficial location of the extensor mechanism makes it susceptible to injury.

  • Etiology: Rupture of the quadriceps is an infrequent but disabling injury that requires prompt diagnosis and treatment. It most commonly occurs in those older than 40 and peaks in the 6th and 7th decades with a 8:1 male to female predominance. The tear can range from partial to complete and involve any portion(s) of the trilaminar tendon, typically initiates centrally/transversely at the osteotendinous junction and progresses peripherally through the vasti and proximally to involve the rectus femoris. Ruptures are most commonly caused by rapid, eccentric contractions of the quadriceps muscle as it lengthens while less intensive or simultaneous bilateral injuries are the result of underlying medical conditions that compromise vascular supply and pathologically alter the integrity of tendinous architecture. Other mechanisms of injury include trauma, lacerations, and iatrogenic causes.

  • Clinical Presentation: Clinical presentation includes the triad of acute pain, inability to actively extend the knee, and the pathognomonic suprapatellar gap.

  • Diagnostic Studies: Diagnosis can often be confirmed with imaging modalities such as plain radiographs, ultrasound and MRI – the latter two of which have replaced the more invasive arthrography.

  • Management: Nonsurgical management is the accepted course of treatment for incomplete tears while timely surgical repair is recommended to achieve optimal functional results in complete ruptures. Delaying surgery often complicates the repair process and has resulted in suboptimal functional outcome. Despite the lack of contraindications, repair of quadriceps tendon rupture is never a surgical emergency and its urgency must be weighed against optimization of potential comorbidities (e.g. polytrauma, systemic conditions, expected functional recovery, etc.) to ensure that the patient is an appropriate surgical candidate.

1. What is the urgency of the surgery?

What is the risk of delay in order to obtain additional preoperative information?

Repair of quadriceps tendon rupture is not a surgical emergency. Thorough preoperative evaluation should be conducted to ensure appropriate surgical candidacy. Data surrounding the optimal timing of surgical intervention remains controversial. Numerous studies have shown good results with immediate repair and unsatisfactory results with delayed intervention, while others have shown no correlation between timing of repair and surgical outcomes. Delaying surgery introduces the issue of muscle retraction, which may require a lengthening procedure to achieve acceptable repair.

i. Emergent: Repair of quadriceps tendon rupture is never a surgical emergency. Delaying surgery introduces issue of muscle retraction, which makes eventual repair more challenging and may adversely affect long-term functional outcome.

ii. Urgent: Following tendon rupture, quadriceps loses its distal insertion and begins to retract within in 48 to 72 hours. Retractions can complicate surgical repair by making apposition of torn ends difficult, often requiring quadriceps lengthening and/or tendon or muscle transfer, and increasing the tension along corrected suture lines. Surgical repair of acute ruptures should ideally commence within the initial 72-hr window following injury.

  • Siwek and Rao evaluated 36 ruptures and found that surgical repair within the first 2 weeks after acute rupture yielded good to excellent results while those treated after 4, 12 and 14 weeks after injury had unsatisfactory outcomes based on range of motion and strength. Rougraff et al reviewed 53 ruptures and reported significantly poorer functional results, lower satisfaction scores, and lower isokinetic data in patients with delayed treatment. Contrary to above, Konrath et al failed to show a correlation between the length of time from tendon rupture to surgical repair and the final strength, functional score, or activity score through functional surveys and objective testing in 51 quadriceps tendon ruptures in 39 patients.

iii. Elective: No large series of surgical repair of chronic (neglected) disruptions is available. Since muscle retraction has already occurred and large gap exists between the tendon edges, the urgency of surgical repair is less applicable in this setting. Measures should be taken to assure appropriate surgical candidacy.

iv: Conservative/Medical management: Conservative treatment is indicated for incomplete ruptures.

v: Recommendation: Data suggest that earlier intervention leads to better functional outcome while delaying repair (other than for medical or surgical optimization) has no benefit and could potentially adversely affect surgical approach and outcome. Urgent intervention is therefore recommended but the technical and anatomical reasons supporting urgency leave a 72-hour window in which medical optimization could occur. Despite the controversy between early versus delayed repair, what remains consistent is the finding that surgical repair can provide reliable results with good range of motion recovery but residual weakness.

2. Preoperative evaluation

Patients who present for repair of quadriceps tendon rupture range from young athletes with traumatic injury to the elderly with systemic comorbidities that accelerate tendon degeneration. Initial evaluation should focus on the etiology of injury and stability of the patient as a surgical candidate followed by optimization of any comorbid conditions. As routine medical clearance can often lead to unnecessary delay, goal of preoperative evaluation should focus on comorbidities that can alter anesthetic management or for which optimization may lead to better perioperative outcome.

Management of the trauma patient is beyond the scope or intent of this chapter. Should the injury be traumatic in nature, surgical repair of the quadriceps tendon should be delayed until any life-threatening injuries have been addressed, adequate resuscitation has been achieved, and the patient has recovered adequately from co-existing injuries so the new baseline physiology would not present an unacceptable risk to the patient during subsequent procedures.

  • Medically unstable conditions warranting further evaluation include (but not limited to): acute myocardial ischemia or infarction, uncontrolled or unstable arrhythmias, decompensated heart failure, COPD exacerbation, unexplained hematological disturbances including coagulopathy, severe and reversible hepatic or renal impairment, stroke, TIA, uncontrolled seizures, electrolyte/metabolic abnormalities, or intoxicated states.

  • Delaying surgery may be indicated if: patient presents with unstable medical conditions for which evaluation may alter anesthetic management and/or optimization will significantly reduce perioperative risk or improve perioperative outcome.

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

Approximately 20% of patients with unilateral ruptures and 30% of those with bilateral spontaneous ruptures present with pathologic conditions that negatively affect tendon integrity (either by accelerating fatty degeneration or tendon infiltration, or by decreasing collagen content) and contribute to its subsequent rupture — including hyperparathyroidism, chronic renal failure, gout, obesity, leukemia, rheumatoid arthritis, diabetes mellitus, systemic lupus erythematosus, infection, metabolic disease, chronic steroid use or abuse, tumors, and immobilization. Optimization of underlying disorders should be considered prior to proceeding with elective surgery.

a. Cardiovascular system

i. Perioperative evaluation: The American College of Cardiology and American Heart Association (ACC/AHA) 2007 guidelines on perioperative cardiovascular evaluation and care for noncardiac surgery proposed an algorithm for decisions regarding the need for further evaluation based on urgency of procedure, presence of active cardiac conditions (ie. unstable coronary syndrome, decompensated heart failure, significant arrhythmias, or severe valvular disease), patient’s clinical risk factors and functional capacity, and the predicted cardiac risk of the planned procedure. Repair of the ruptured quadriceps tendon is a non-emergent, intermediate-risk procedure which should proceed unless patient presents with an active cardiac condition or if further non-invasive testing would change perioperative management.

  • Acute/unstable conditions: Per ACC/AHA guidelines, active cardiac conditions should be stabilized prior to proceeding with non-emergent surgery. If indicated by clinical history or exam, workup may include 12-lead EKG, echocardiogram, continuous cardiac monitoring, cardiac biomarkers, temporary pacemaker or cardioverter-defibrillator, or cardiology consultation.

  • Baseline coronary artery disease (CAD) or cardiac dysfunction – Goals of management: To establish severity and potential progression of disease through clinical history, existing EKG, echocardiogram, or stress testing, and consider initiating or change therapy if it would reduce perioperative cardiac risk.

ii. Perioperative risk reduction strategies:

  • Monitoring:

    Standard ASA monitors.

    Advanced hemodynamics monitoring as indicated by clinical findings (ie vulnerable myocardium, severe valvular disease, etc), providers’ expertise, and institutional support.

    Arterial line

    CVP, PA catheter

    TEE

  • Goals: to optimize oxygen supply and demand ratio.

    Increase oxygen supply

    FiO2: supplemental O2; consider 100% FiO2 with ventilatory strategies to minimize atelectasis.

    Hemoglobin: maintain adequate level of oxygen carrying capacity.

    Heart rate: avoid tachycardia and consider utilization of beta blockers or calcium channel blockers in order to decrease demand and increase time in diastole.

    Coronary perfusion pressure: optimize gradient between diastolic pressure and left ventricular pressure.

    Decrease myocardial demand

    Heart rate: beta blockers and calcium channel blockers reduce rate and oxygen consumption.

    Contractility: avoid high contractile states.

    Afterload: optimize afterload to allow adequate coronary perfusion without producing excessive left ventricular pressure.

    Preload: maintain preload in favorable part of Frank-Starling curve to achieve adequate stroke volume and cardiac output without causing increased pressure work.

b. Pulmonary

Patients with pulmonary disease are at increased risk of postoperative dysfunction following general anesthesia. Preoperative evaluation focuses on identifying and modifying risk factors that contribute to postoperative pulmonary dysfunction.

i. COPD:

  • Perioperative evaluation: careful clinical history include pack year smoked, frequency of exacerbations, current symptomatic control, oxygen requirement, medication regimen, and available studies (spirometry). Unless suspecting acute exacerbation, pulmonary testing may be unnecessary and delay surgery.

  • Perioperative risk reduction strategies:

    Continue current pulmonary medications perioperatively; consider starting nebulizer, steroid therapy if appropriate (severe disease)

    Initiate maneuvers intraoperatively to avoid obstructive exacerbation or barotrauma

    Consider anesthetic techniques that avoid airway instrumentation, mechanical ventilation, or medications that alter hypoxic/hypercarbic thresholds. If regional anesthesia is used, try to avoid high blocks as some patients rely on accessory muscles for adequate respiration

    If airway instrumentation is unavoidable, ensure adequate depth of anesthesia or utilize bronchodilator therapy to reduce risk of bronchospasm

    Utilize ventilatory strategies that mimic baseline COPD physiology (ie lower I:E ratio, PEEP, lower peak airway pressures, etc.)

    Continue pulmonary therapy postoperatively with pulmonary toilet, incentive spirometry, nebulizer and steroid therapy if indicated

ii. OSA The severity of sleep apnea should be assessed preoperatively, and appropriate intra-operative airway management applied to prevent obstruction if sedation is used in conjunction with a surgical regional anesthetic. Post-operatively, these patients may be at greater risk of over-sedation and airway obstruction with opioid analgesics. Dosages should be minimized, regional analgesic techniques used when possible, and patients should use their CPAP machines. If they are not currently on CPAP, oxygen saturation should be closely monitored post-operatively and CPAP provided if ventilation becomes inadequate.

iii. Reactive Airway Disease (Asthma):

  • Perioperative evaluation: assess severity of disease including frequency of exacerbations, triggers, control and rescue medications, recent steroid therapy, ER visits, hospitalizations, ICU admissions, or prior intubations.

  • Perioperative risk reduction strategies:

    Continue control medications perioperatively and consider course of nebulizer or steroid therapy if patient has moderate to severe disease

    Consider anesthetic technique that avoids airway instrumentation

    If general anesthesia is unavoidable, ensure adequate depth of anesthesia or consider bronchodilatory agents to reduce risk of bronchospasm

c. Renal-GI:

Chronic renal failure leads to changes within the collagen structure itself while uremia can weaken the quadriceps mechanisms by causing muscle fiber atrophy via disruption of protein-polysaccharide complex in collagen.

i. Perioperative evaluation: 20+ million adults in United States have chronic kidney disease with the population of dialysis-dependent patients increasing 3-5% annually. Overall perioperative mortality rates in this patient population range from 1% to 4%; common causes of mortality include sepsis, bleeding, congestive heart failure, hypotension, and hyperkalemia.

  • Preoperative evaluation:

    Cause and severity of renal failure

    Extent and management of coexisting disorders: diabetes, hypertension, renovascular diseases, etc.

    Presence of multiorgan involvement (ie, CHF, pulmonary hypertension, pleural or pericardial effusion, anemia, renal osteodystrophy, multiple myeloma, vasculopathy, etc.)

    Dialysis dependence:

    Patient’s dry weight & current volume status (these patients often have intravascular volume deficit following dialysis)

    Dialysis schedule and last dialysis session

    Electrolytes

    Urine production

    Sites of current or old arteriovenous fistulas or presence of peritoneal dialysis catheters

    History of renal transplant:

    Dry weight

    Response to transplant

    Electrolytes

    Position of transplanted kidney(s) and presence of native kidney

    Immunosuppressive medications

    Diagnostics: if indicated by history or clinical exam

    CBC with platelet count

    Electrolytes, including Na+, K+, Ca++, Mg++, BUN, and creatinine (K+ should be checked on day of surgery if patient is on dialysis)

    EKG may show hyperkalemic changes (peaked T waves, widened QRS, and flat P waves; progress to sinusoidal waveform) or indicate presence of large pericardial effusion (electrical alternans)

    Echocardiography can be considered to evaluate ventricular function and diagnose valvular disease, pericardial effusions, or pulmonary pressures.

    Testing can cause unnecessary delay and should be considered only if the results are expected to changes anesthetic management or improve perioperative outcome

ii. Perioperative risk reduction strategies:

  • Volume status:

    Maintain euvolemia and perfusion pressures. Consider correcting perioperative fluid deficit from overnight fasting, bowel preparation, diarrhea, and vomiting prior to induction of anesthesia

    Avoid fluid overload in patients with marginal renal function or dialysis dependence

  • Medications:

    Continue immunosuppressives for patients with renal transplants

    Avoid nephrotoxic drugs (ie, aminoglycosides, NSAIDs, etc)

    Most pharmacologic renoprotective interventions have proved ineffective or may increase morbidity and mortality. There is little evidence to support their use in renoprotection. Drugs studied include: dopamine agonists, selective dopamine-1-receptor agonist (fenoldopam), furosemide, and mannitol

Gastrointestinal/Hepatobiliary: There’s no disease-related GI issue; standard NPO guideline should be followed and pharmacologic aspiration prophylaxis considered.

d. Neurologic:

i. Perioperative evaluation:

  • There are no disease-related neurologic disorders associated with quadriceps tendon ruptures. Perioperative neurologic evaluation should focus on the assessment and optimization of existing neurologic comorbidities.

  • Signs and symptoms of transient ischemic attack or stroke, inadequately controlled seizures, acute neurologic decompensation should lead to additional workup prior to proceeding with elective procedure.

  • Clinical history and exam will guide the need for additional testing (Ct, MRI, carotid doppler, echocardiogram, or neurology consultation).

ii. Perioperative risk reduction strategies:

  • Patients with neurovascular or carotid occlusive disease may have altered cerebrovascular autoregulation and necessitate higher systemic pressure to maintain cerebral perfusion pressures. Invasive hemodynamic monitoring may be considered.

  • Antiepileptic medications can induce hepatic enzymes and cause increased metabolism (reduced half-life) of commonly used anesthetic agents (ie. muscle relaxants).

  • Regional anesthesia is not contraindicated but the benefits of neuraxial techniques should be balanced against the risk of sympatholysis and reduced cerebral perfusion pressures.

e. Endocrine/Metabolic:

Endocrinopathies can lead to structural compromise of the quadriceps tendon. Diabetes can precipitate vascular changes within the tendon. Obesity causes fatty degenerative changes in the tendon. Hyperparathyroidism causes dystrophic calcifications and subperiosteal bone resorption, which weakens the osseotendinous junction and leads to tendon rupture. The use of steroids can cause microscopic damage to the vascular supply, altering the normal architecture of the tendon and thus increasing its susceptibility to complete rupture.

i. Perioperative evaluation:

  • Assess type, severity and control of endocrinopathy

  • Evaluate presence of end-organ dysfunction as a result of primary endocrinopathy (e.g. diabetic neuropathy or nephropathy, stiff-joint syndrome, acid-base disturbances, cognitive deficits from hyperparathyroidism/hypercalemia, etc.)

  • Review appropriate medical therapy and initiate perioperative pharmacologic regimen

  • Consider diagnostic testing to confirm presence of potential end-organ dysfunction (ie, EKG, electrolyte panel, blood glucose, echocardiogram, thyroid function tests, etc.)

  • Disease-specific considerations:

    Diabetes

    Identify type of diabetes, current glycemic regimen and adequacy of control

    Potential multiorgan involvement include CAD with silent ischemia, retinopathy, nephropathy, peripheral and autonomic neuropathy, gastropathy, cerebrovascular disease, peripheral vasculopathy, and stiff joint syndrome

    If indicated by clinical history or exam: blood glucose, electrolyte panel including serum creatinine, EKG, HgbA1c, or advanced cardiac testing per ACC/AHA guidelines

    Hyperparathyroidism

    Identify type of hyperparathyroidism

    Primary: inappropriate or autonomous hypersecretion of PTH from parathyroid glands, causing hypercalcemia

    Secondary: occurs in setting of chronic renal insufficiency when there is glandular hyperplasia from continuous stimulation from hyperphosphatemia and hypocalcemia

    Tertiary: results from prolonged secondary parathyroidism when glands enlarge and become autonomous, leading to oversecretion of PTH and hypercalcemia

    Assess for signs and symptoms of hyper- or hypocalcemia

    Hypercalcemia: “Stones, Bones, Abdominal Moans, and Psychiatric Groans”

    Cognitive deficits, hypertension, EKG conduction changes (shortened QT), hyporeflexia, muscular weakness/atrophy, fatigue, abdominal pain, constipation, nausea/vomiting, PUD, polyuria, nephrolithiasis, volume depletion, etc

    Hypocalcemia: neuronal irritability – Chvostek and Trousseau signs, perioral or acral paresthesia, spontaneous tetany, altered mental status, seizures; signs of heart failure – dyspnea, peripheral edema, hypotension, dysrhythmia, catecholamine resistance; cataracts; laryngospasm, stridor or apnea.

    Hypercorticalism

    Identify cause and assess appropriate workup or management (ie, iatrogenic, Cushing’s disease vs. Cushing’s syndrome secondary to neoplastic syndrome with ACTH or CRH production, adrenal aldosteronoma/hyperplasia, etc)

    Evaluate dose and duration of steroid therapy and predict risk of hypothalamic-pituitary-adrenal (HPA) axis suppression and adrenal insufficiency

    HPA axis is suppressed with > 20mg/day of prednisone or its equivalent for > 3 weeks

    HPA is not suppressed with < 5mg/day of prednisone equivalent

    HPA may or may not be suppressed if 5 to 20mg/day of prednisone equivalent is taken for > 3 weeks

    Risk of adrenal insufficiency remains for up to 1 year after the cessation of high-dose steroid therapy

    Assess control of comorbidities – hypertension, CAD, osteoporosis, obesity, myopathy, glucose intolerance or frank diabetes mellitus, and immunosuppression or opportunistic infections

    If indicated by clinical history or exam: Electrolyte panel, serum glucose, EKG

ii. Perioperative risk reduction strategies:

  • Diabetes:

    Surgery for diabetics (especially type 1) should be scheduled as the first case of the day

    Pre-, intra-, and postoperative blood glucose levels should be monitored

    Continue all insulin regimens as scheduled until the day of surgery (DOS)

    Hold all oral agents on DOS and hold off on restarting metformin if there is risk of renal and/or hepatic failure; when used as single-agent therapy, several of the newer oral agents (acarbose, pioglitazone) do not carry risk of hypoglycemia in the fasting patient

    Use modified insulin regimen (ie 1/2 of regularly schedule long-acting insulin) on DOS according to established institutional protocol

    For patients on insulin pump, continue only basal rate on DOS or consider recruiting endocrinology input prior to DOS

  • Hyperparathyroidism:

    Avoid medications that potentiate hypercalcemia (ie calcium-containing antacids, hydrochlorothiazide diuretics, and lithium)

    Treat moderate hypercalcemia (> 12-14mg/dL) with IV hydration, furosemide, and adequate salt and water intake

    Consider delaying case in severe hypercalcemia (> 14mg/dL) as condition can be life-threatening. Treat with saline hydration, diuretics, bisphosphonates, calcitonin, mithramycin, and glucocorticoids

    Monitor for digitalis toxicity

  • Chronic intrinsic or extrinsic steroid exposure:

    Anticipate intravascular volume and electrolyte abnormalities

    Assess coexisting myopathy as these patients show increased sensitivity to muscle relaxants or may have postoperative respiratory insufficiency

    If on chronic steroid therapy, patients should continue their glucocorticoid or mineralocorticoid replacement therapy on DOS

    Consider steroid supplementation for major procedures in patients with Cushing’s syndrome or in patients taking > 20mg/day of prednisone equivalent

f. Additional systems/conditions which may be of concern in a patient undergoing this procedure and are relevant for the anesthetic plan.

i. Rheumatoid arthritis (RA): causes chronic inflammatory changes resulting in synovitis and diffuse fibrosis.

  • Perioperative evaluation:

    Evaluate onset and course of the disease, location and severity of joint involvement, triggers, and history of other organ system involvement

    Arthropathy:

    Temporamandibular joint, cervical spine, and cricoarytenoid cartilages are commonly affected

    High incidence of atlantoaxial subluxation in patient population; symptomatic patients may benefit from preoperative c-spine radiographs. Those with neuralgia or myelopathy may need neurology consultation and/or surgical intervention (halo or surgical stabilization)

    Neurologic: vasculitis and nerve entrapment have been documented with RA

    Cardiac: pericardial effusion, aortic insufficiency, and conduction abnormalities are common

    Pulmonary: Pleural effusions, interstitial fibrosis, and decreased thoracic mobility may produce restrictive defect

    Renal: renal vasculitis

    Hematologic: anemia, leucocytosis, thrombocytosis, and splenomegaly with thrombocytopenia can occur

    Endocrine: adrenal insufficiency from glucocorticoid therapy, impaired immune system

    Dermatologic: rheumatoid nodules, dry eyes, vasculitis, and salivary inflammation

    Review history of disease modifying anti-rheumatoid drugs used and potential adverse effects (ie pancytopenia, hepatotoxicity, immunosuppression, adrenal insufficiency, renal insufficiency, platelet dysfunction, etc.)

    Per clinical history and exam, following supportive studies or consultations may guide anesthetic management: airway and c-spine range of motion exam, c-spine films, CBC with platelet count, electrolyte panel, liver function tests, EKG, PFTs, or consultative specialist input (otolaryngology, neurosurgery, cardiology, etc.)

  • Perioperative risk reduction strategies:

    Careful planning of airway management

    Prepare for difficult laryngoscopy and minimize risk of atlantoaxial subluxation during C-spine manipulation.

    Use small diameter endotracheal tubes in presence of cricoarytenoid involvement.

    In high-risk patients (symptomatic cervical instability, presence of predictors for difficult airway, etc), consider aware fiberoptic intubation and neurologic assessment prior induction of general anesthesia

    Consider anesthetic options which avoid airway manipulation (ie regional anesthesia)

    Treatment of opportunistic infection(s)

ii. Gout: causes tophaceous synovitis and fibrinoid necrosis of the tendon.

iii. Systemic lupus erythematosus: causes microscopic vascular damage and alters the normal architecture of the tendon, thus increasing the susceptibility to complete rupture.

  • Perioperative evaluation: investigates the severity of disease, course of treatment, recent exacerbations, medications and side effects, and specific end-organ disease. Systems of interest include:

    Cardiac: pericarditis, myocarditis, endocarditis, premature CAD, coronary vasculitis, and reversible cardiomyopathy

    Pulmonary: pleural effusion, interstitial pneumonitis, pulmonary hypertension

    Renal: lupus nephritis and renal insufficiency

    Neurologic: cognitive dysfunction, peripheral neuropathy, cerebrovascular disease, vascular headaches, and seizures

    Hematologic: anemia, leukopenia, thrombocytopenia, antiphospholipid antibody syndrome with increase risk of thromboembolic complications

    Infectious: immunosuppressive therapy leads to opportunistic infections

    Musculoskeletal: migratory arthritis, myositis, Raynaud’s phenomenon

    Diagnostics: should be considered if results are expected to guide anesthetic management or improve perioperative outcome. Studies may include: CBC, platelets, coagulation panel (ie elevated aPTT in those with antiphospholipid antibody syndrome), electrolyte panel, serum creatinine, EKG, echocardiogram, chest radiograph, PFT, etc.

  • Perioperative risk reduction strategies:

    Optimize cardiovascular and pulmonary involvement prior to elective surgery

    Initiate appropriate thromboembolism prophylaxis especially in setting of antiphospholipid antibody syndrome and keep patients warm to minimize peripheral vasospasms

    Existing peripheral neuropathy does not exclude the use of regional anesthesia, which can be implemented after careful documentation of pre-existing neural deficits

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

Average patient undergoing repair of ruptured quadriceps tendon is a middle-aged male with well-controlled, mild systemic disease(s). Medications commonly seen in the perioperative setting include antihypertensives, statins, insulin or oral hypoglycemic agents, anti-inflammatory agents, and opioid analgesics. Perioperative strategies including medication management have been discussed in the sections above and additional comments will be included in the following section.

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

  • Cardiac:

    Beta-blockers: should be continued perioperatively with goal heart rate less than 70 BPM. Continuation of beta-blockers in intermediate- and high-risk cardiac patients may reduce adverse cardiac events perioperatively. Starting beta-blockers perioperatively, however, may be associated with an increased incidence of stroke and death (POISE trial).

    Statins: should be continues perioperatively as discontinuation is associated with increased risk of adverse cardiac events and mortality.

    Antihypertensives: should be taken on day of surgery (DOS) except for patients undergoing high-risk procedures where hypotension may be detrimental, in which case angiotensin-converting enzyme inhibitors (ACEIs) or angiotensin receptor blockers (ARBs) may be discontinued prior to DOS.

    Other cardiac medications (ie, digoxin): should be continued on DOS.

  • Pulmonary: Control medications such as inhaled beta agonists, leukotriene inhibitors, corticosteroids, and oral therapy should be continued perioperatively. In moderate or severe disease, additional therapy (nebulizerd beta agonist, course of steroids, etc) may be considered.

  • Renal: Diuretics should be taken on day of surgery, especially when used as part of an antihypertensive regimen.

  • Neurologic: Antidepressants (including monoamine oxidase inhibitors), anxiolytics, antiepileptics, and medications for psychomotor disorders (ie. Parkinson’s) should be continued perioperatively. Antiplatelet therapy taken for cerebrovascular disease will be discussed below.

  • Antiplatelet agents:

    Aspirin: should be continued unless the risk of bleeding outweighs the risk of thrombosis. If reversal of platelet inhibition is necessary, then aspirin should be discontinued 7 days prior to surgery. Do NOT discontinue aspirin in patients who have drug-eluting coronary stents until they have completed 12 months of antiplatelet therapy (1 month for bare-metal stents) unless the patient, surgeon, and cardiologist have discussed the risks of discontinuation. Aspirin as a sole antiplatelet agent is not a contraindication to neuraxial techniques. If discontinued, it should be restarted as soon as appropriate postoperatively.

    Thienopyridines (IIB/IIIA platelet inhibitors, e.g. clopidogrel): follow same recommendation as aspirin to balance the risk of thrombosis/restenosis versus increased bleeding. This class of medication contraindicates neuraxial techniques.

    NSAIDS or COX-2 inhibitors: can be continued to DOS unless there is increased risk of bleeding or bone healing for planned procedure.

  • Endocrine:

    Oral hypoglycemics: should be avoided on DOS.

    Insulin: Institutional protocols may vary but most adhere to discontinuation of all short-acting insulin on DOS and administration of up to 1/2 of long-acting or combination insulins on DOS. Patients with insulin pump should continue their basal rate only.

    Thyroid analogs: should be continued on DOS.

  • Misc:

    Herbals and nonvitamin supplements: should be discontinued 7 days prior to surgery.

    Viagra, Cialis, or similar drugs: should be discontinued 24 hours prior to surgery.

    Oral contraceptives: can be continued on DOS.

    Opioid analgesics: can be continued on DOS. The use of partial agonists/antagonists may interfere with typical perioperative pain regimen and should be discussed with pain specialist prior to DOS.

    Steroids: should be continued on DOS without need for stress dose supplementation unless patient is scheduled for high-risk procedure or at increased risk for adrenal insufficiency.

    Heartburn or reflux medications (e.g. proton pump inhibitors or H2 blockers): should be continued on DOS.

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

see previous section

How To modify care for patients with known allergies –

Avoid medications to which the patient is allergic

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

  • Identify at-risk patients and determine type and severity of allergic reaction

    Risk factors: history of multiple surgical procedures (spina bifida, congenital urinary tract anomalies); work place exposures (health care and rubber industry workers); history of atopy; food allergy to tropical fruits (kiwi, banana, avocado), chestnuts, or stone fruits; and previous reaction to latex products.

    Types of reactions:

    Contact dermatitis:

    most frequently observed reaction

    not immune mediated

    caused by drying action of cornstarch and other chemical in gloves

    Type IV delayed hypersensitivity:

    immune-mediated allergic response to chemical additives

    skin reactions appear 6-72 hours post-exposure

    may progress to a type I reaction

    Type I immediate hypersensitibity:

    IgE mediated response

    begins within minutes of exposure

    symptoms range from mild (skin redness) to life threatening (bronchospasm and cardiovascular collapse)

    Perioperative management:

    Coordinate between anesthesia, surgical and nursing staff to provide latex-free environment.

    Warning signs should be placed on patient’s chart, bed, and both inside and outside the OR.

l. Does the patient have any antibiotic allergies-

Avoid antibiotics to which the patient is allergic.

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

  • Documented- avoid all trigger agents such as succinylcholine and inhalational agents:

    Proposed general anesthetic plan:

    Insure MH cart available:

    [- MH protocol]

    Family history or risk factors for MH:

  • Local anesthetics/ muscle relaxants: Allergies to local anesthetics are rare. If to the amino-ester drugs, there is no cross-reactivity to the amino-amides, and the latter can be used safely.

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

Laboratory testing should be based on clinical indications (ie. pathophysiologic process, positive findings from history and exam, etc) and only if results would alter perioperative management or outcome. Unbiased testing in patients with no risk for having the pathophysiologic process tested can yield a unacceptably high number of false-positive results, unnecessary follow up evaluation and delay of needed surgical intervention.

Common laboratory normal values will be same for all procedures, with a difference by age and gender

  • Hemoglobin levels: routine hemoglobin or platelet determination is not indicated unless patient has known hemopathy or the procedure is associated with significant blood loss. Current recommendation of the National Blood Resource Education Committee is that a hemoglobin of 7g/dL is acceptable in patients without systemic disease, and >10g/dL in those with known CAD or requiring increased oxygen carrying capacity.

  • Electrolytes: are not needed routinely prior to this procedure unless indicated by comorbid conditions (ie, potassium in patients with renal insufficiency, on dialysis or potassium-wasting diuretics; sodium in volume depletion or SIADH; or BUN/creatinine in renal failure or hypovolemia).

  • Coagulation panel: is not routinely indicated assuming the absence of positive findings in the history or physical examination.

  • Imaging: preoperative EKG, echocardiogram, CXR, invasive cardiac testing (stress test or angiography) may potentially offer more information regarding patients’ underlying systemic disease but should not be ordered routinely unless patient has severe systemic disease and results will affect perioperative management or outcome.

  • Other tests: Spirometry rarely provides additional information beyond that obtained by history. Pregnancy testing in women of child-bearing age is controversial; selective testing may be more appropriate in patients with risk factors.

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

Surgical concerns: Several surgical approaches are available — direct repair of the tendon to the patella, the Scuderi technique for the acute tears and the Codivilla tendon-lengthening technique for chronic tears. Details of specific technique will not be discussed here but the general concept with anesthetic implications is included.

  • Technique: A straight midline vertical incision from mid-to-distal thigh to inferior patellar margin or tibial plateau is most commonly utilized to expose the extensor mechanism; procedure can also be accomplished through a transverse incision. The tear is identified and irrigated, and the torn tendon edges are debrided back to healthy tissue. Midsubstance ruptures can be treated with end-to-end primary repair if sufficient tendon remains. Ruptures at the osteotendinous junction may be repaired through bony trough and drill holes in the patella. If tendon cannot be re-approximated as in the case of chronic ruptures, the Codivilla tendon lengthening technique is used.

  • Tourniquet: The use of a thigh tourniquet is surgeon dependent. While the use of a tourniquet decreases bleeding and improves operative environment, it can compromise the repair by tethering the quadriceps and making it harder to mobilize.

  • Duration and postoperative plan: Duration of procedure depends on complexity of repair; on average, repairs take approximately 60-90 minutes. Patients are discharged home on the same day in a hinged knee brace and start motion either same day or at the first follow-up appointment in 5-7 days. No neuromuscular assessment is performed immediately postoperatively.

  • Recommendation: As with any procedure, brief discussion with the surgeon will clarify potential anesthetic needs.

Anesthetic options: The procedure can be performed under general anesthesia or regional anesthesia (spinal, epidural, combined spinal-epidural, lumbosacral plexus or peripheral nerve blocks). There are no outcome studies surrounding the various anesthetic techniques in the repair of quadriceps tendon ruptures. Comparative studies on anesthetic options in major orthopedic procedures (ie total knee or hip arthroplasties) have not demonstrated significant differences in morbidity or mortality between regional and general anesthesia.

i. Regional anesthesia

  • Neuraxial: Spinal, epidural, combined spinal-epidural anesthesia, lumbosacral plexus block .

    Benefits:

    blunting of the neuroendocrine response to surgery.

    decreased intraoperative blood loss and perioperative transfusion requirement.

    higher vascular graft survival rate.

    amelioration of the hypercoagulable perioperative state leading to lower incidence of thromboembolic events (less applicable in the era of aggressive pharmacologic thromboembolism prophylaxis).

    reduced morbidity (possibly even mortality) in high-risk surgical patients.

    extension of analgesia into the postoperative period.

    improved pulmonary function from decreased splinting following upper abdominal or thoracic surgeries.

    earlier return of gastrointestinal function postoperatively.

    reduced postoperative opioid requirement.

    avoidance of complications associated with general anesthetics (ie trauma to oropharyngeal structures, bronchospasm, aspiration, atypical response to anesthetic agents or malignant hyperthermia).

    potentially shorter emergence and recovery phase.

    spinals: technically easier, faster onset of blockade with higher success rate and less risk of systemic local anesthetic toxicity, better quality of sensory and motor blockade when compared to epidurals.

    epidurals: less risk of post-meningeal puncture headaches and more gradual changes due to sympatholysis when compared to spinals. Catheter technique allows for intraoperative extension of block duration and postoperative analgesia.

    combined spinal-epidural: rapid onset with capability for intraoperative redosing and postoperative analgesia.

    Drawbacks:

    takes longer to initiate than general anesthesia but may potentially save time on postoperative care (postoperative pain, nausea, vomiting, discharge times).

    risk of post-meningeal puncture headaches.

    risk of neuraxial hematoma, infections, and nerve damage.

    transient radicular irritation (TRI) and transient neurologic symptoms (TNS)

    hemodynamics disturbances secondary to sympatholysis may not be tolerated (ie CAD, aortic stenosis, CVD).

    misc: backaches, urinary retention, hearing loss, systemic toxicity, total spinals.

    could potentially delay discharge depending on agents used.

    Issues:

    appropriate patient selection: comorbidities (ie, obstructive sleep apnea, restless leg syndrome, chronic back pain), surgical positioning, and duration of surgery may dictate needed or tolerated level of sedation.

    contraindicated or limited in patients taking anti-platelet therapy, on anticoagulation, or have pre-existing coagulopathy. For guidance, please refer to 2010 Regional Anesthesia in the Patient Receiving Antithrombotic or Thrombolytic Therapy: American Society of Regional Anesthesia and Pain Medicine Evidence-Based Guidelines (Third Edition) .

    Lumbar plexus block may be sufficient if procedure is done via a transverse incision without the use of tourniquet; lumbosacral plexus blocks or addition of sciatic nerve block can provide surgical anesthesia f tourniquet is used or if incision extends into sciatic distribution.

  • Peripheral Nerve Block: Femoral nerve block placed proximal to inguinal ligament can achieve sufficient surgical anesthesia. Supplemental sciatic nerve block may be needed if tourniquet is used or if incision extends inferiorly into sciatic distribution. Femoral nerve block or catheter technique can also be used as an adjunct to postoperative analgesic regimen.

    Benefits:

    can be used in patients with contraindications to neuraxial blockade.

    can be combined with neuraxial technique or general anesthesia as a part of a successful postoperative analgesic regimen.

    less hemodynamic disturbance compared with general or neuraxial anesthesia.

    does not delay postoperative discharge.

    decreases postoperative analgesic requirement.

    Drawbacks:

    requires additional block equipment (block kit, nerve stimulator, ultrasound, etc).

    greater risk of systemic toxicity and when compared to neuraxial blocks.

    technically challenging.

    time: takes longer to perform and establish block

    positioning for block may cause mild to moderate discomfort.

    anxiolosis and/or sedation is often needed for both block placement and intraoperative management.

    Issues:

    abolition of ability for immediate postoperative neural assessment.

    anatomic site(s) for nerve block will vary depending on anesthetic needs (ie, proximal femoral and sciatic nerve blocks are needed for tourniquet pain, whereas lower blocks can be utilized for surgical anesthesia without use of tourniquet or for postoperative analgesia.

ii. General Anesthesia

  • Benefits:

    ability to secure airway and institute appropriate ventilatory strategies

    provides adequate intraoperative amnesia and hypnosis

    depth and duration of anesthesia can be easily regulated

    provides safety margin for chronically combative or delirious patients

  • Drawbacks:

    adverse effects from anesthetic agents (postoperative nausea/vomiting, cognitive dysfunction, etc.)

    variations in hemodynamics

    abolition of protective airway reflexes and increased aspiration risk

  • Other issues:

    requires additional plan for postoperative analgesia (ie, acetaminophen, NSAIDs, opioids, nerve blocks)

    patients at risk for aspiration or postoperative nausea and vomiting should receive appropriate pharmacologic prophylaxis

  • Airway concerns:

    NPO and aspiration risk should be assessed to help determine method of securing airway

    cervical spine instability or rigidity may be encountered in patients with rheumatoid arthritis or diabetes, respectively. Precautions and advanced airway adjuncts (fiberoptic bronchoscope, video laryngoscope, etc) should be instituted for spine stabilization or potentially difficult laryngoscopy/intubation.

iii. Monitored Anesthesia Care: not an option since the extent of repair may involve structures distant to the repair site (ie. traction of quadriceps tendon/muscle, retraction of the retinaculum, tourniquet application, etc.) and not be covered by local anesthetic infiltration or require an amount of local anesthetic in excess of what is considered safe.

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

Outcome studies surrounding the repair of ruptured quadriceps tendon is lacking. Although there are extensive data on the advantage of regional anesthesia over general anesthesia for total hip and knee arthroplasties, those advantages are not entirely applicable to the less extensive quadriceps repair in the ambulatory setting. The choice of anesthetic plan depends on patient’s underlying health (cardiopulmonary reserve) and perioperative risks (PONV, POCD, or respiratory complications), anticipated surgical approach and duration, patient’s preference (of expected level of anxiolysis, analgesia, and postoperative care), and contraindications to particular anesthetic options.

Neuraxial block is the preferred anesthetic in this patient population — middle-aged male with few systemic diseases who are undergoing elective surgery in the ambulatory setting — as it is easy to perform, provides reliable surgical anesthesia even with tourniquet application, decreases perioperative opioid consumption, allows quicker emergence and cognitive recovery, and potentially decreases the incidence of PONV and time to discharge. Chloroprocaine spinals are used for procedures that can be reliably completed within 60 minutes; 10-25 micrograms of spinal fentanyl is occasionally added to extend the duration of spinal anesthesia to 75-80 minutes; the addition of epinephrine to chloroprocaine spinal is not recommended due to development of flu-like symptoms in human volunteer subjects. If the anticipated duration of surgery is longer than 90 minutes, a continuous epidural or combined spinal-epidural technique can provide option for extending surgical anesthesia without introducing the risks associated with intermediate-duration spinal anesthetics (TNS, prolonged block, and delayed discharge).

Regardless of the type of primary anesthetic, a continuous femoral nerve catheter is used to supplement postoperative analgesia. Patients who utilized femoral nerve catheters following total knee arthroplasties have earlier functional recovery than those without perineural block, but similar results have not been demonstrated in those undergoing quadriceps repairs. Patients are discharged home with an ambulatory perineural infusion pump and catheters are discontinued in 2-3 days.

  • What prophylactic antibiotics should be administered? The most recent Surgical Care Improvement Project recommendations published in October 2009 recommends the use of cefazolin or cefuroxime as antibiotic prophylaxis in orthopedic procedures. Vancomycin or clindamycin can be utilized as substitutes in patients with beta-lactam allergy. Institutional protocols should be updated periodically to reflect changes in SCIP recommendations.

  • What do I need to know about the surgical technique to optimize my anesthetic care?

    Technique: A straight midline vertical incision from mid-to-distal thigh to inferior patella margin or tibial plateau is most commonly utilized to expose the extensor mechanism; procedure can also be accomplished through a transverse incision. The tear is identified and irrigated, and the torn tendon edges are debrided back to healthy tissue. Midsubstance ruptures can be treated with end-to-end primary repair if sufficient tendon remains. Ruptures at the osteotendinous junction may be repaired through bony trough and drill holes in the patella. If tendon cannot be re-approximated as in the case of chronic ruptures, the Codivilla tendon lengthening technique is used.

    Tourniquet: The use of a thigh tourniquet is surgeon dependent. While the use of a tourniquet decreases bleeding and improves operative environment, it can compromise the repair by tethering the quadriceps and making it harder to mobilize.

    Duration and postoperative plan: Duration of procedure depends on complexity of repair; on average, repairs take approximately 60-90 minutes. Patients are discharged home on the same day in a hinged knee brace and start motion either same day or at the first follow-up appointment in 5-7 days. No neuromuscular assessment is performed immediately postoperatively.

    Recommendation: As with any procedure, brief discussion with the surgeon will clarify potential anesthetic needs.

  • What can I do intraoperatively to assist the surgeon and optimize patient care?

    Decreased muscle tone may be needed to assist reapproximation of torn tendons. This can be achieved with neuraxial anesthesia, volatile anesthetic or occasionally the use of neuromuscular blockers. It is unlikely that neural monitoring is needed during this procedure but one should discuss this rare contraindication to neuromuscular blockade with the surgeon prior to its administration.

    If tourniquet is not used, controlled hypotension may be requested to help minimize blood loss. This technique can reduce blood loss as well as duration of surgery but one must balance the risks of inadequate end-organ perfusion versus the benefits states above.

  • What are the most common intraoperative complications and how can they be avoided/treated? The repair of ruptured quadriceps tendon is a low-to-moderate risk procedure in terms of perioperative cardiopulmonary complications. There lacks a procedure-specific complication (ie, Cement implantation syndrome for total joint arthroplasties) and typical perioperative risk reduction strategies as listed in sections above should be followed.

  • Cardiac complications:

    optimize perioperative myocardial supply and demand.

    assess need for invasive monitoring.

    avoid factors that contribute to worsening of myocardial supply and demand ratio (hypoxia, tachycardia,excessive hypo- or hypertension, shivering, poor anxiolysis or pain control, etc).

    institute beta-blocker protocol, continue antiplatelet therapy if appropriate, and consider postoperative cardiac evaluation and cardiac monitoring if indicated by intraoperative events.

  • Pulmonary complications:

    avoid airway instrumentation in reactive airway disease.

    provide ventilatory strategies to reduce risk of intraoperative atelectasis, bronchospasm, airtrapping, or barotrauma.

    continue pulmonary therapy postoperatively with pulmonary toilet, incentive spirometry, continuous positive airway pressure device, nebulizer, and steroid therapy if indicated.

  • Thromboembolic complications:

    use lower extremity compression device on non-operative extremity.

    encourage early ambulation.

    aggressive antithrombotic prophylaxis if appropriate.

  • Neurologic complications are rare.

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

No special criteria is needed for extubation. Patients should be neurologically intact with return of protective airway reflexes and adequate pulmonary function (oxygenation and ventilation) prior to extubation.

c. Postoperative management

  • What analgesic modalities can I implement?

    In the ambulatory setting, patients are initially treated with parenteral NSAIDs (ketorolac) and opiates until they are able to tolerate PO intake. PO analgesics such as acetaminophen, COX-2 inhibitors or NSAIDs, and potentially low-dose gabapentin have been part of a successful multimodal analgesic regimen and can reduce perioperative opioid requirement. Single injection blocks and continuous peripheral nerve catheters have also dramatically revolutionized perioperative pain control.

    If patients are routinely admitted per institutional protocol, then IV PCA, continuous epidural or spinal opioids can also be used in addition to the above options, provided that safety protocols are in place to minimize complications (ie delayed respiration suppression from epidural/spinal morphine, increased fall risk with epidural local anesthetics, delirium and PONV from IV PCA).

  • What level bed acuity is appropriate? Patients are discharged same day for those with uncomplicated perioperative course.

  • What are common postoperative complications, and ways to prevent and treat them?

    Postoperative delirium:

    Rule out neurologic, metabolic and pharmacologic causes of mental status change.

    Avoid drugs with central nerve system effects – anticholinergics, antihistamines, benzodiazepines, opioids, and antipsychotic medications.

    Postoperative DVT/PE:

    Initiate prophylactic measures (SCDs, pharmacologic prophylaxis with heparin or warfarin, early ambulation).

    Prompt diagnosis and treatment if DVT is suspected.

    Surgical complications:

    Loss of knee motion or residual extensor weakness.

    Surgical site infection or skin dehiscence, which are related to subcutaneous positioning of wires and/or the large-caliber nonabsorbable sutures used for surgical repair.

    Hemarthrosis, which can be minimized with the use of closed suction drain.

    Patella alta or baja (patella incongruity) which can lead to subsequent patellofemoral degeneration.

    Re-rupture of the repaired tendon requiring revision surgery.

What's the Evidence?

Insall, JN, Scott, WN. “Surgery of the Knee.”. 2001.

Ilan, DI, Tejwani, N, Keschner, M, Leibman, M. “"Quadriceps Tendon Rupture."”. Journal of the American Academy of Orthopaedic Surgeons. vol. 11. 2003. pp. 192-200.

Hines, RL, Marschall, KE. “Stoelting's Anesthesia and Co-Existing Disease.”. 2008.

Sweitzer, BJ. “Preoperative Assessment and Management.”. 2008.

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