Common Orthopaedic Procedures Flashcards
Elective vs trauma procedures… what are they and the difference?
Elective - a planned procedure, does not need to be performed immediately
Eg, joint replacement, ligament reconstructions
Trauma - used to treat/manage traumatic injuries
Eg. ORIF - open reduction internal fixation, external fixation
Cauda equina decompression - not from trauma but still emergency therefore comes under this
What is a joint replacement and why are they done?
Orthopaedic surgery procedure in which an arthritic or dysfunctional joint surface is replaced with a prosthesis
Most commonly replaced - hips and knees
Can also replace - shoulders ankles finger joints
Mostly elderly due to arthritis, but do see younger as well
Joint replacements
Total hip replacement (THR/THA - arthroplasty) -
Mostly performed under a spinal anaesthetic (blocks sensation from waist down)
Incision made postero-laterally to expose the joint
Surgeon then dislocates hip joint
Femoral head cut off and special tool used to grind down and reshape the acetabulum
Acetabular cup placed into socket, then an insert/liner placed inside the cup
Prosthetic femoral stem is placed into the shaft of the femur and the prosthetic femoral head sits on top of the stem
Muscles and other soft tissues are repaired, skin incisions stitched.
Joint replacements
What is a hemiarthroplasty?
Surgical procedure that involves replacing half of the hip joint
Replaces ONLY the femoral head portion of the joint
Alternative to a THR/A
Joint replacements
What is hip resurfacing?
Replaces the surfaces of the hip joint - preserves more bone than an THR
Head of femur is not removed, but is reshaped to allow a metal cap to be cemented onto it.
Alternative to THR
Joint replacements
Total knee replacement (TKR/TKA) -
Normally under spinal anaesthetic
Knee is flexed, incision made down the front of the knee to expose the kneecap
Kneecap is moved to the side to allow access to the knee joint
Distal femur and proximal tibia are cut away, using guides which shape the bone to fit the prosthetic components
Distal end of the femur is replaced with a curved metal prosthesis, and the proximal tibia is replaced with a flat prosthesis
Plastic spacer in between the two components
Sometimes the posterior aspect of the patella is also replaced
Joint replacements TKR
What can sometimes be done before surgery ?
What is unicompartmental knee replacement?
Sometimes can attach a ‘dummy joint’ first and test movement and assess size before doing the prosthesis
Uni = only on one side, normally will just be on medial side
Recovery is much quicker
Joint replacements
TKR and THR post-op physio -
Start mobilising on day 0 if possible
ROM/strength exercises - incorporating aids if necessary eg, crutches, how to walk with them.
Hip precautions are sometimes followed for 6/52 - not in Leicester! Depends on hosp protocol
Swelling management - cryotherapy/ice
Pain management
Avg stay on ward is 2-3 days. Normally no longer than 5
Joint replacements
Complications of TKR and THR -
Post op infection - symptoms ted to line up with norm symptoms after surgery eg, swelling
Therefore need to pay really close attention!!!
Infection probs most common
DVT - harder to spot in upper leg
Wells score - determines a patients risk of a DVT
Malfunctions of prosthesis
Nerve injury
Joint replacements
Total shoulder replacement (TSR)
Aims and traditional prodcedure -
Aims - reduce pain and restore mobility in patients with late stage shoulder OA, or after severe fracture
Traditional - GHJ accessed anteriorly
Deltoid and pecs separated to access shoulder J
Subscapularis cut to gain access to
Arthritic areas removed
Implants inserted
Subscapularis repaired and incisions closed
Joint replacements
TSR, reverse procedure -
Reverse allows patient to use deltoid to compensate for a torn RC
Shoulder accessed anteriorly
Humerus prepared for new socket (humeral cup) and glenoid prepared for ball shaped prosthesis
Humeral stem inserted, humeral cup and glenosphere attached - may be attached with cement or may be ‘press fit’
Movement of joint checked
Muscles repaired, incisions closed
joint replacement TSR
Post op physio -
Early - sling for 2/52, will be taught how to use it
ROM exercises as allowed
Taught how to complete ADL
Pain management
Weeks 2-6 - wean out of sling
Progress ROM - ensure god scapula rhythm
Start isometric RC exercises (if allowed)
Weeks 6-12 - as above but start to progress strength and functional activities
Up to 6months - patient specific rehab depending on goals
ACL reconstruction -
Undergone in patients who have ruptured their ACL
Hamstring/patella tendon used as graft (autograft)
Similar outcomes, hamstring - higher risk or hamstring injury post op, smaller wound, high strength of graft
PT - increase risk of tendinopathy/ant. Knee pain. Normally would use middle 1/3 and maybe take small bits of bone as well
9-12 months rehab for return to sport post op
ACL reconstruction
Autograft -
Alograft -
Auto - harvested from patients own body. Most commonly used as reduces likelihood of further damage of ACL
Alo- harvested from somewhere else
Eg. Meniscus surgery - often use cadaver meniscus
*not common for ACL
ACL reconstruction
Post op rehab -
9-12 months rehab for return to sports
Initial phase - gait education, AROM and strenghtening
Early - progression of ROM/strength - closed chain quads, early proprioception
Cycling
Middle - continue to progress strength and ROM if required
Progress proprioceptive exercises, load acceptance
Running - straight line, then progress to multi directional
Late - start sport specific drills - norm from 6/12 onwards depending on patient progress
- also important to train non-operated leg!!!
Rotator cuff repair -
Indicated in patients with complete tears of rotator cuff tendons, or sometimes for partial tears who have failed conservative treatment
Normally done arthroscopically, although can be down as an open surgery
Surgeon will start with EUA (examination under anaesethic)
Joint/tendon with be debrided, sometimes alongside a subacromial decompression (removal or bone spurs from the underside of the clavicle)
Rotator cuff tendons will then be reattached to the bone using an anchor and sutures (dif variations depending on surgeon)
RC repair
Post op rehab -
3-6 months rehab
Shoulder normally isn’t allowed to be weight beared at first for a awhile
Early phase - immobilised for up to 6/52 in sling
Middle phase - AROM and scapula stability
Late phase - shoulder strengthening, proprioception
Sports specific rehab
Achilles repair -
And what’s done after -
Indicated in patients with Achilles rupture - can be treated conservatively or surgically (similar outcomes)
Thompson test to identify
Posterior incision made
Ruptured ends of Achilles stitched together
Normally put in a boot, in plantar flexion for 8-12/52
^ allows healing to continue, whilst gradually increasing length of tendon
Initially likely to be TTWB (toe touch weight bearing)
Directory/decompression overview -
Indicated in patient who have nerve root or spinal cord compression - could be bc of disc prolapse, bony spurs in the intervertebral foramen or spinal canal stenosis
Surgery is urgent in case of Cauda equina symptoms
Surgery AROM - reduce compression to nerve and/or spinal cord
Can be a discectomy, a decompression or both
Often performed in both lumbar and cervical spine
Disectomy -
Decompression -
Where is incision?
Involves removing disc material that is extruding into the foramen/spinal canal
Decompression - can include removal of osteophytes, laminectomy, removal of thickened ligament, foraminotomy, facetectomy
Central posterior incision made over the appropriate vertebrae, spinal muscles are split down the middle and moved to either side to gain access to spine.
Disectomy/decompression
Post op physio -
Sitting often restricted to 30 mins at a time for first 1-2/52
Gentle ROM and isometric exercises given initially
Walking encouraged from immediately post-op
Strength and mobility exercises progressed from 4-6/52 post op depending on symptoms
Spinal fusion -
Can either be elective or trauma surgery - indicated in some cases of nerve root compression, unstable spondylolisthesis, unstable fractures, scoliosis
Surgeon uses screws and rods to fix vertebra in place
Scoliosis correction = very painful
Immediate post op aimed at regaining mobility
Chest physio also required
Other common orthopaedic surgeries
Debridement -
Menisectomy -
Debridement - cleaning out a joint
Eg arthroscopically - tissue, loose bodies, scar tissue to improve joint function
Men - meniscal tear that can’t be repaired - as most of meniscus doesn’t have a blood supply
Trim off loose bit
Other common orthopaedic surgeries
Labral repair -
Micro fractures -
What else is common?
Labral - hip/shoulder joints
Micro - less common eg defect in cartilage or bone
Drill holes, therefore encourages bleeding, clotting occurs and forms scar tissue
Therefore replacing cartilage at that surface.
*muscle/ligament/tendon reconstructions
Open reduction internal fixation (ORIF) -
Surgery used to fix broken bones that are displace or unstable
Different types of fixation - nail or plates/screws are most common
Open reduction refers to the process of resetting the bones in the correct position
Internal fixation is then the use of the implant to maintain this position, allowing bone to heal
Fixation will often remain in place unless metalwork becomes problematic (eg infection), at which point it may be removed
ORIF, dynamic hip screw -
Common in older osteoporotic patients
Indicated in case of fractured neck of femur
Allows some movement (real benefit) of the femoral head in the direction of the screw, therefore promotes remodelling and healing
External fixation -
Surgical treatment where the rods are screwed into the bone, and exit the body to be at attached to a stabilising structure
Indicated in the case of severe pen fractures,infected non-unions, correction of malalignments, poly trauma
Sometimes laws for weight bearing in LL fractures which can promote healing
Can remain in place for weeks/months
Aim is always to remove them
Rehab starts whilst ex-fix still in place
