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A U E R S & T > Chapter 81 - Surgical treatment of joint disease > Flashcards

Chapter 81 - Surgical treatment of joint disease Flashcards

1
Q

Which two main treatment goals are highlighted for equine joint disease?

A

Pain relief for functional use of the joint and arrest of disease progression.

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2
Q

What type of joint disease is typically treated with medical management and exercise protocols?

A

Generalized osteoarthritis (OA).

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3
Q

What are the two main functions of arthroscopy in joint disease management?

A

Diagnostic and therapeutic functions.

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4
Q

How is arthroscopy considered when compared to more complex imaging modalities?

A

It is viewed as the gold standard due to its specificity and sensitivity.

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5
Q

What novel technique is being researched alongside arthroscopy for assessing cartilage and subchondral bone?

A

Near infrared spectroscopy (NIR).

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6
Q

What kind of information can optical coherence tomography (OCT) provide during arthroscopy?

A

Detailed, quantitative information about morphology of articular cartilage lesions.

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7
Q

What has increased awareness of joint pathology in the stifle joint led to?

A

Increased recognition of meniscal and cruciate lesions that are not detectable by radiography.

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8
Q

What is one potential benefit of lavage during arthroscopy?

A

The egress of joint fluid that may contain cytokines and cartilage wear particles.

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9
Q

In what type of cases is arthroscopy generally found to be more therapeutically beneficial?

A

Acute cases, rather than chronic cases.

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10
Q

Which chronic pathologies can sometimes be managed successfully with arthroscopy?

A

Osteonecrosis and cartilage fibrillation of the third carpal bone.

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11
Q

Why do newly detached osteochondral fragments have a better treatment outcome if removed early?

A

Because early removal before OA develops prevents further joint degeneration.

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12
Q

What is the main challenge associated with performing arthroscopy in terms of visual clarity?

A

Bleeding of intrasynovial tissues can impair visualization unless inert gas is used for distention.

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13
Q
A

Figure 81-1. Arthroscopic image of a chip fragment off the distal radial carpal bone before (A) and after removal (B).

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14
Q
A

Figure 81-2. (A) Arthroscopic image of a slab fracture of the third carpal bone before reduction. (B) Lateromedial radiographic view of the slab fracture seen in (A) after reduction and fixation using a 4.5-mm cortex screw in lag fashion.

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15
Q

Name the % for each prognosis:
excellent
good
guarded
poor

A

excellent 80% to 90% chance of athletic soundness
good 60% to 80%
guarded 40% to 60%
poor <40%

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16
Q

What are the joints with good surgical removal of the osteochondral chip?

A

1 . extensor process
2. dorsal frontal p1 displaced and nondisplaced
3. proximodrosal P1
4. Plantar P1 (exceelent)
5. Palmar P1 (excellent)
6. Apical sesamoid
7. Abaxial sesamoid
8. Proximal RC
9. Proximal IC
10. Distal IC

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17
Q

What are the joints with guarded surgical removal of the osteochondral chip?

A
  1. P2 not involving DIP joint
  2. Palmar P1
  3. Basilar Sesamoid
  4. Distal RC
  5. C3
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18
Q

What are the joints with poor surgical removal of the osteochondral chip?

A
  1. P2 involving DIP joint
    and medical treatment of apical sesamoid
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19
Q

Under what conditions are osteochondral fragments typically removed from horses?

A

Fragments are removed when diagnosed in conjunction with clinical lameness.

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20
Q

Why might some osteochondral fragments be left in place?

A

If they are considered relatively benign and the horse does not exhibit clinical lameness.

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21
Q

How has the routine use of arthroscopy affected the outcomes of osteochondral fragment removal?

A

It has improved outcomes compared to removal using arthrotomy.

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22
Q

What is the general procedure for removing multiple osteochondral fragments?

A

Smaller fragments are typically removed first to avoid excessive portal size and maintain visualization.

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23
Q

What is the significance of arthroscopic visualization when reconstructing intraarticular fractures?

A

It ensures proper alignment and optimal repair of the articular component for better outcomes.

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24
Q

What tools are often used to prepare the parent bone during osteochondral fragment removal?

A

Hand curettes are used to débride the bone and smooth edges.

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25
Q

Name two common types of intraarticular fractures encountered in equine athletes.

A

Condylar fractures of the third metacarpus (MCIII) and slab fractures of the third carpal bone.

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26
Q

What technique is commonly used for internal fixation of intraarticular fractures?

A

Lag technique with screws.

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27
Q

What is the primary purpose of performing a synovectomy in horses?

A

To aid arthroscopic visualization and as a therapeutic treatment for conditions like septic arthritis.

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28
Q

How can the removal of synovium contribute to the treatment of septic arthritis?

A

It helps eliminate fibrin that may harbor bacteria, preventing recurrence of infection.

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29
Q

In which equine joints is synovial membrane removal or synovectomy most frequently performed?

A

Tarsocrural, distal interphalangeal, and elbow joints.

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30
Q

What methodologies have been used for conducting synovectomy in horses?

A

Surgery, chemicals, and radioisotopes, with motorized synovial resection being the most common surgical method.

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30
Q

Why is complete understanding of the synovial membrane’s role in equine joint disease still developing?

A

The role is not as well characterized as in humans, particularly in various forms of arthritis.

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31
Q

What are the two main types of damage typically described in equine articular cartilage?

A

Chronic degenerative lesions and acute damage.

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31
Q

What is the typical assessment approach for evaluating the outcome of cartilage repair?

A

Assessment is based on biochemical content, histologic appearance, biomechanical properties, and functional outcomes.

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31
Q

Why do partial-thickness lesions and full-thickness articular cartilage lesions not heal spontaneously in horses?

A

Due to the specialized structure of articular cartilage and its limited regenerative capacity.

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32
Q

When treating cartilage lesions, what approach is generally taken concerning the degree of débridement?

A

Minimally débride the cartilage, only removing damaged areas while leaving intact cartilage in place.

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33
Q

What are the three classes of surgical options for cartilage repair mentioned in the text?

A

Palliative, reparative, and restorative.

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34
Q

What does reparative surgical care include?

A

Marrow stimulation techniques, including microfracture.

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35
Q

How are modern surgical techniques for cartilage repair evolving?

A

Techniques are combining methods and augmenting them with growth factors and other treatments for improved outcomes.

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36
Q

Intra-articular fractures which ones are good prognosis?

A
  1. Distal phalanx (except extensor process)
  2. Proximal phalanx simple non-disp
  3. Proximal phalanx noncommunituded displaced
  4. MCIII/MTIII (noncommun)
  5. MCIII/MTIII (complete nondisplaced)
  6. MCIII/MTIII (incomplete nondisplaced)
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37
Q

Intra-articular fractures which ones are poor prognosis?

A
  1. Middle phalanx comminuted (S and M)
  2. Proximal phalanx comminuted
  3. Proximal sesamoid (midbody)
  4. MCIII/MTIII displaced
  5. C3 slab medical tx
  6. C3 slab saggittal
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38
Q

Intra-articular fractures which ones are excellent prognosis?

A
  1. MCIII/MTIII (incompl, nondisplac) S and M tx
    2.
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39
Q

Intra-articular fractures which ones are guarded prognosis?

A
  1. Distal halanx (type II) (M)
  2. Middle phalanx (comminuted M or S
  3. MCIII/MTIII comminuted
  4. C3 slab (frontal)
  5. C3 slab (sagittal)
40
Q
A

Figure 81-3. Arthroscopic image of microfracture spacing on the medial femoral condyle.

41
Q

What is the primary role of bone marrow in cartilage repair?

A

Bone marrow provides stem cells and growth factors essential for cartilage health and repair.

42
Q

Name three growth factors important in cartilage repair.

A

Insulin-like growth factor-1 (IGF-1),
transforming growth factor-β (TGF-β),
bone morphogenetic proteins (BMP) 2 and 7.

42
Q

Which surgical technique involves débridement to the level of the subchondral bone plate?

A

Abrasion arthroplasty.

43
Q

What is spongialization in the context of cartilage repair?

A

Débridement past the subchondral plate into cancellous bone.

44
Q

How deep should microfracture holes penetrate into the bone?

A

to access cells and growth factors beneath the subchondral plate without disrupting its biomechanical stability.

44
Q

Why is spongialization not favored in current clinical practice?

A

It is thought to destabilize the subchondral bone plate.

44
Q

What are the current recommendations for treating articular lesions?

A

Débridement to the level of the subchondral bone plate or in conjunction with subchondral bone microfracture.

45
Q

How deep should microfracture holes penetrate into the bone?

A

Approximately 2 mm.

45
Q

What is the purpose of subchondral bone microfracture?

A
46
Q

What outcome did the study involving 44 horses find regarding microfracture?

A

No proven association between microfracture use and long-term outcomes.

47
Q

What is a recent advancement in microfracture techniques?

A

The use of an injectable self-assembling peptide hydrogel.

48
Q

What did biochemical analyses reveal about repair tissues following microfracture?

A

Increased amounts of aggrecan and type II collagen compared to hydrogel alone.

49
Q

What is the consequence of drilling the subchondral bone plate?

A

Formation of subchondral bone cysts and poor histologic appearance of repair tissue.

50
Q

What is the significance of achieving petechial bleeding during débridement?

A

It indicates proper depth of débridement without entering cancellous bone.

51
Q

What does a granular appearance of the defect indicate?

A

The differentiation between the subchondral bone plate and the calcified cartilage layer.

52
Q

What does ACI stand for in cartilage resurfacing techniques?

A

Autologous Chondrocyte Implantation.

52
Q

Which grafting techniques have been used in cartilage defects?

A

Periosteal and perichondrial autografts,
osteochondral grafts,
chondrocyte autografts or allografts,
and stem cell transplants.

53
Q

What is the average duration of pain resolution or improvement after microfracture?

A

2 to 3 years.

53
Q

How does the patient satisfaction with microfracture compare to ACI in long-term follow-ups?

A

Minor significant improvement with microfracture over ACI, but no significant differences in histologic appearance or outcomes.

54
Q

What are the limitations of using periosteal and perichondrial grafts in horses?

A

Disappointing results and no longer a focus of research.

55
Q

What is the main challenge with osteochondral grafting in horses?

A

Lack of congruity between recipient and donor tissues and surgical technique difficulties.

56
Q

What harvesting region is typically used for autologous chondrocyte harvesting?

A

A non-weight-bearing region, usually the trochlea of the distal femur.

57
Q

What are the advantages of the MACI technique over traditional ACI?

A

It uses a three-dimensional biodegradable material, reducing the need for multiple surgeries.

58
Q

What is a significant finding from experimental trials using a modified MACI technique in horses?

A

It has shown superior outcomes compared to ACI.

59
Q

What role do frozen chondrocytes harvested from neonatal foals play in cartilage repair?

A

They have shown success in limited chondral defects and are used more commonly in cystic defects.

60
Q

What is a major hurdle in using mesenchymal stem cells for cartilage defects in horses?

A

Accessing a sufficient number of stem cells without in vitro expansion.

61
Q

What is the purpose of using fibrin glue in cartilage defect treatments?

A

To retain cells in the chondral defect and enhance grafting success.

62
Q

What has research indicated about the long-term results of osteochondral plugs in horses?

A

At 12 months, transplanted areas appeared smooth, but some biopsies showed loss of glycosaminoglycans.

63
Q

What type of collagen is increased in repair tissues after microfracture?

A

Type II collagen.

64
Q

How are microfracture holes spaced during the procedure?

A

2 to 3 mm apart.

65
Q

What challenge does the ACI technique face in equine applications?

A

High cost, need for multiple surgeries, and technical challenges.

65
Q

What did the systematic analysis of microfracture outcomes reveal about knee function?

A

Improved function in all studies during the first 24 months, but conflicting long-term results.

66
Q

What type of cartilage defect treatment technique is considered promising for future equine use?

A

One-step techniques like the cartilage autologous implantation system (CAIS).

66
Q

What was a significant limitation identified in the equine osteochondral grafting techniques?

A

Morbidity at the donor site due to lack of suitable non-weight-bearing regions.

66
Q

Why might some clinical impressions of microfracture outcomes vary?

A

Possible functional deterioration and variable repair cartilage volume.

67
Q

What is a potential future direction for cartilage repair research mentioned in the text?

A

The use of bioprinted osteochondral constructs and ECM components.

68
Q

How does the technique of chondrocyte transplantation function?

A

Autologous chondrocytes are harvested, expanded in vitro, and implanted into defects.

69
Q

What is the significance of the study comparing ACI and subchondral bone microfracture?

A

It highlights differences in short-term and long-term results between the two techniques.

70
Q

Why is the microarthroscope important in assessing débridement levels?

A

It confirms the level of débridement by visualizing the defect margins.

71
Q

What factor contributes to poor attachment of repair tissue after microfracture?

A

Incomplete removal of the calcified cartilage layer.

72
Q

What ongoing research areas are focused on improving cartilage repair?

A

Bioprinting techniques and the application of mesenchymal stem cells.

73
Q

What is the primary indication for performing arthrodesis?

A

Destruction of a joint beyond the scope of other treatments.

74
Q

What is the expected outcome of arthrodesis for high-motion joints?

A

Alleviation of pain associated with movement and salvage for nonathletic function.

74
Q

Which joints typically require surgical fusion using internal fixation?

A

High-motion joints such as the antebrachiocarpal, midcarpal, metacarpophalangeal, and distal interphalangeal joints.

75
Q

What is the prognosis for athletic soundness in low-motion joint arthrodesis?

A

It often carries a reasonable prognosis for athletic soundness.

75
Q

What methods can be used for arthrodesis?

A

Surgical, chemical, or laser-based techniques.

76
Q

What risks are associated with chemical fusion of joints?

A

Unexpected anatomic communications with other structures and potential injury from overdistension.

77
Q

What is the current trend regarding the use of laser techniques in distal tarsal joint arthrodesis?

A

Early morbidity reports favor continued use of surgical arthrodesis over laser techniques.

77
Q

What preliminary studies have compared surgical drilling to laser ablation in distal tarsal joints?

A

Initial studies indicated that drilling may lead to quicker bony union, while laser procedures may reduce lameness resolution time.

78
Q

What is the typical lifespan of a joint implant?

A

Generally 10 to 20 years, depending on the implant type and location.

78
Q

When are joint replacements typically considered for patients?

A

When reparative procedures have failed and medical management is unresponsive.

79
Q

What challenges hinder equine joint replacement from becoming mainstream?

A

Cost of implants, difficulties with non-weight-bearing recovery, and surgical morbidity.

80
Q

What is a common goal in postoperative aftercare protocols?

A

To minimize the duration to full function return while maintaining athletic soundness.

81
Q

What support measures are often used in aftercare following joint surgery?

A

Bandaging, casts, and controlled exercise.

82
Q

Why is controlling postoperative inflammation important?

A

It benefits the healing process and reduces complications.

83
Q

When does maximal inflammation typically occur in a surgical wound?

A

3 to 5 days postoperatively.

84
Q

What medications are often used to control postoperative inflammation?

A

Systemic nonsteroidal anti-inflammatory medications.

85
Q

Why are corticosteroids contraindicated in the first four weeks post-surgery?

A

They can decrease cell metabolism, prolong healing time, and impair immune function.

86
Q

What substances have been studied for their chondroprotective qualities?

A

Hyaluronan and polysulfated glycosaminoglycans (e.g., Adequan).

87
Q

What has been a notable finding regarding the effectiveness of chondroprotective substances in postoperative healing?

A

They have not shown significant benefit in most studies, except in reducing adhesions in tendon sheaths.

88
Q

What emerging area in equine care is focused on enhancing postoperative recovery?

A

The field of equine rehabilitation, employing multimodal approaches for recovery.

A U E R S & T (121 decks)

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