Monitored Anesthesia Care and Soft-Tissue Infiltration With Local Anesthesia for Short Cephalomedullary Nailing in Medically Complex Patients: A Technique Guide

Abstract

Hip fractures are increasingly common and often occur in patients with complex medical comorbidities. There remains a need for a safer anesthetic option for these patients for the operative repair of their injury other than general or neuraxial anesthesia. At our institution, for medically complex and physiologically tenuous patients, we perform Monitored Anesthesia Care and Soft-Tissue Infiltration of Local Anesthetic (MAC-STILA) when performing percutaneous fixation techniques for hip fractures. We describe our technique here.

Keywords: hip fracture; local anesthesia; mac-stila; monitored anesthesia care; short cephalomedullary nailing.

Figure 1. Preoperative radiographs (a and b) and CT scans (c and d) of a right basicervical (OTA/AO 31-B2.1) femoral neck fracture. Note the osseous abnormalities resultant from the patient’s renal osteodystrophy.

Figure 2. Preoperative preparation for monitored anesthesia care and soft-tissue infiltration of local anesthetic (MAC-STILA)

a) Patient positioning for short cephalomedullary nailing (CMN). b) Landmarks marked for short CMN incisions, as well as targets for the STILA corresponding to the nail entry point to the greater trochanter, the head lag screw, and the distal interlock screw. c) Similar landmarks for a different patient for a left hip. d) Supplies required for STILA: 2.5 mg/kg of 0.25% bupivacaine, 22-gauge spinal needle, 50-60 cc syringe, 0.9% normal saline.

Figure 3. Soft-tissue infiltration of local anesthetic (STILA) procedure

a) 50% total volume of bupivacaine solution injected in the proximal nail entry trajectory from the skin down to the tip of the greater trochanter (GT) periosteum. b) Intraoperative fluoroscopy demonstrating spinal needle at GT. c) 30% total volume of bupivacaine solution injected in the lag screw trajectory from the skin down to the vastus ridge. d) Intraoperative fluoroscopy demonstrating spinal needle at the vastus ridge. e) 20% total volume of bupivacaine solution injected in the distal interlock trajectory from the skin down to lateral femur. f) Intraoperative fluoroscopy demonstrating spinal needle at the lateral femoral cortex.

Figure 4. Post-operative fluoroscopy images after short cephalomedullary nailing anteroposterior (AP) (a) and cross-table lateral (b). One-year follow-up AP (c) and cross-table lateral (d) radiographs