Orthopaedic surgery in the elderly

The orthopaedic surgeon brings to the operating room some of the greatest challenges for the anaesthesiologist. Various factors, such as age, health status, disease process, type and extent of operative procedure, provide differing circumstances, which an anaesthesiologist is obliged to cope with. This contrasts to other surgical specialities in which patient factors and operative procedures are much more predictable. The number of older patients in orthopaedics is steadily growing, and the anaesthesiologist has to take all measures to permit an early and efficient rehabilitation, a concept which is now widely recognized for improving the success of orthopaedic surgical procedures. Factors which may hinder this concept are post-operative pain, central nervous system dysfunction, fatigue, deep sedation, delayed enteral feeding and absorption. There is no evidence that regional anaesthesia without the use of the continuous regional analgesic technique decreases morbidity and mortality as compared to general anaesthesia, in this context. However, the advantages of continuous analgesia through a perineural spinal or epidural catheter are promising and deserve further investigation. The concept of the optimal post-operative multimodal regimen needs to be defined. The application of NSAID and paracetamol is an integral part of this concept, and the dose of opioids should be titrated to the lowest efficient dose needed. Thus, this chapter discusses the different controversies and future trends of anaesthesia with regard to the elderly in orthopaedic surgery.