Journal of Clinical Anesthesia (2010) 22, 565–572 Review article Anesthesia for patients undergoing orthopedic oncologic surgeries Michael R. Anderson MD (Fellow)a, Christina L. Jeng MD (Assistant Professor)a,b, James C. Wittig MD (Associate Professor)b, Meg A. Rosenblatt MD (Professor)a,b,⁎ aDepartment of Anesthesiology, Mount Sinai School of Medicine, New York, NY 10029-6574, USA bDepartment of Orthopaedics, Mount Sinai School of Medicine, New York, NY 10029-6574, USA Received 12 November 2009; revised 23 February 2010; accepted 23 February 2010 Keywords: Abstract When planning an anesthetic for patients undergoing orthopedic oncologic surgeries, Anesthesia; numerous factors must be considered. Preoperative evaluation may elucidate significant co-morbidities Orthopedic; or side effects secondary to chemotherapy or radiation, which can affect anesthetic choices. Procedures Bone tumors; vary in length and complexity and pose challenges in both positioning and in planning to minimize Chrondrosarcoma; blood loss. Many anesthetic techniques are available to provide both intraoperative anesthesia and Ewing's sarcoma; postoperative analgesia, while the type of thromboprophylaxis and analgesic adjuvants that will be Orthopedic oncologic administered needs to be defined. This review focuses on approaches to use when caring for patients surgery; undergoing orthopedic oncologic procedures. Osteosarcoma; © 2010 Elsevier Inc. All rights reserved. Patient positioning; Thromboprophylaxis 1. Introduction 2. Primary bone sarcomas The National Cancer Institute reports that there were There are three common primary bone sarcomas. approximately 2,600 new cases of primary bone malig- Osteosarcoma, the most common bone sarcoma, has an nancies in 2009 as well as numerous other metastatic incidence of 4.6 per million people. The majority of these bone tumors. Despite the relatively common frequency, tumors occur in patients between 10 and 19 years of age, there is a paucity of information about the delivery of but there is also an association with Paget's disease in anesthesia for orthopedic oncologic surgeries. There are adults who are older than 40. Fifty percent of osteosarco- preoperative, intraoperative, and postoperative concerns mas arise around the knee, and they are also often seen in specific to these patients and procedures which, therefore, the upper arm. Ewing's sarcoma is primarily a disease of merit discussion. adolescence, with a peak incidence of about three cases per million in the 15 to 19-year age group. Although rare, Ewing's sarcoma is the second most common bone sarcoma affecting children and adolescents. It is more prevalent in ⁎ Corresponding author. Tel.: +1 212 241 7467; fax: +1 212 876 3906. men; it affects Caucasians primarily; and it frequently E-mail address: [email protected] (M.A. Rosenblatt). occurs in the spine, pelvis, arm, or leg. Chondrosarcoma is 0952-8180/$ – see front matter © 2010 Elsevier Inc. All rights reserved. doi:10.1016/j.jclinane.2010.02.011 566 M.R. Anderson et al. the most common bone sarcoma in adults. It mainly affects Table 1 Chemotherapeutic agents and their common side patients greater than age 50. The incidence is 8 per million effects people. Chondrosarcomas arise most commonly from the Chemotherapeutic Agent Side effects pelvis, upper femur, and shoulder girdle [1]. The prognosis of chondrosarcoma varies depending on the primary DNA-altering drugs Cyclophosphamide Hemorrhagic cystitis location and extent of spread. Myelosuppression Cisplatin Myelosuppression Nephrotoxicity 3. Metastatic tumors Mechlorethamine Myelosuppression Dermatitis Carboplatin Myelosuppression Metastatic bone tumors occur more frequently than Peripheral neuropathy primary tumors. The exact incidence of metastatic bone Immune hypersensitivity reaction disease is difficult to quantify because of the large number of Anti-tumor antibiotics primary cancers that may spread to the skeleton. Breast and Doxorubicin Myelosuppression prostate cancers tend to be the most common causes of bony Cardiomyopathy metastases [2], with up to 70% of patients with advanced Arrhythmias disease developing bone metastases. Lung, kidney, thyroid, Bleomycin Pulmonary fibrosis colon, stomach, bladder, uterine, and rectal malignancies Idarubicin Myelosuppression also metastasize to the bone in 15% to 30% of cases [2].Itis Hepatotoxicity Antimetabolites estimated that 350,000 people a year die with concomitant Gemcitabine Myelosuppression bone metastases [2]. Methotrexate Hepatotoxicity Ulcerative stomatitis Myelosuppression 4. Preoperative considerations Cytarabine Myelosuppression Hyperuricemia Etopiside Myelosuppression Patients who undergo surgery for bony tumors often Hypotension have received considerable medical treatment prior to Antimitotic drugs surgery. Possible side effects of preoperative chemotherapy Vincristine Motor weakness are shown in Table 1. Patients who have undergone Peripheral neuropathy chemotherapy or radiation therapy may have significant Hyponatremia anemia and thrombocytopenia, and thus might benefit from Vinblastine Myelosuppression preoperative exogenous erythropoietin administration and Ulcer/blister formation packed red blood cell (PRBC) or platelet transfusions. Paclitaxel Myelosuppression Paresthesia Obtaining adequate intravenous (IV) access and invasive Docetaxel Myelosuppression monitors in preparation for fluid resuscitation and possible Monoclonal antibody transfusions, may prove challenging secondary to ongoing Cetuximab Skin changes oncologic treatments. If the possibility of large blood loss Electrolyte disturbances from a highly vascular tumor is expected, preoperative Other embolization of the tumor may be beneficial and should be Gefitinib Diarrhea considered [3]. Interstitial lung disease Communication with the surgeon is mandatory prior to Imatinib Edema orthopedic oncologic surgeries. It allows the anesthesiolo- All information adapted from Micromedex/PDR. gist to appreciate the subtleties of each specific procedure (http://www.thomsonhc.com/hcs/librarian, Sept 2010). and to permit the planning for appropriate monitoring DNA = deoxyribonucleic acid. and access. than 12 hours and occasionally require staging. Many 5. Intraoperative considerations procedures often require major neurovascular dissection, removal of significant bone and/or muscle, replacement of There is huge variability of complexity and duration of large segments of bone and adjacent joints that may also orthopedic oncologic surgeries (Table 2). In fact, there are necessitate significant cement boluses for fixation, and approximately 50 different types of procedures performed by rotational and free flaps. A clear understanding of what the orthopedic oncology surgeons. While a bone biopsy may surgery entails allows for proper positioning, airway take less than an hour, a hemipelvectomy may extend more management, and postoperative planning. Anesthesia in orthopedic oncologic surgeries 567 Table 2 Commonly performed orthopedic oncologic surgeries For the prone position, the patient's neck is maintained Above-the-knee and below-the-knee amputation in a neutral position during and after positioning to decrease Above elbow amputation the risk of spinal cord ischemia and stretching of the Currettage of benign and benign aggressive bone tumors and brachial plexus. The eyes should be checked routinely to bone grafting ensure that there is no pressure applied directly to the globe. Distal femur resection with bone and soft-tissue reconstruction Prone positioning has been implicated in the occurrence of Excision of soft-tissue masses postoperative visual loss, especially when accompanied by Fixation of pathological fractures and impending fractures large blood loss or prolonged surgical duration. Depending Forequarter amputation on the area of surgery, the arms are placed either up and Hemipelvectomy adjacent to the head with the elbows flexed or adducted Hip disarticulation alongside the patient. In each case, the arms should be Long-stem arthroplasties and cemented nails padded to prevent compression injuries. Excessive pressure Proximal femur resection with bone and soft-tissue reconstruction on the breasts also must be avoided. The abdomen should Proximal humerus resection with bone and soft-tissue not be compressed because excessive pressure may reconstruction compromise ventilation and decrease venous return from Proximal tibia resection with bone and soft-tissue reconstruction the lower extremities. Total scapula resection and reconstruction, including multiple Poor patient positioning may result in devastating muscle flaps outcomes. The anesthesiologist and surgeon should be Radical lymph node dissections aware of the common pitfalls and attempt to avoid Radical pelvic resections with limb preservation preventable injuries. Radical soft-tissue sarcoma resection with major neurovascular dissections and muscle flaps Radical synovectomy of knee and other joints 5.2. Blood loss Sacrectomy Shoulder disarticulation Tumors are relatively vascular structures and thus are prone to bleeding throughout the intraoperative period. Renal cell and thyroid metastases cause significant neovasculariza- tion to the area, often hemorrhaging dramatically during surgery, much more so than other types of bony metastases. 5.1. Positioning Preoperative embolization of these types of metastases should be considered to minimize bleeding during the Tumors may arise in any portion of the musculoskeletal surgical procedure. The location of the metastasis