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MSK > Cortex- Elective surgery > Flashcards

Cortex- Elective surgery Flashcards

1
Q

what are the surgical strategies for the management of an arthritic joint

A

arthroplasty/ joint replacement
excision or rescection arthroplasty
arthrodesis
osteotomy

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2
Q

what is hemiarthroplasty

A

replacing one half of a joint

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3
Q

what joints can be replaced

A

hip, knee, shoulder, elbow, ankle, 1st MTP joint of the great toe, MCP joints of the hand and wrist

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4
Q

what can joint replacements be made of

A

stainless steel, cobalt chrome, titanium alloy, polyethylene, ceramic

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5
Q

in hip replacements what materials can be coupled

A

metal polethylene
ceramic polyethylene
ceramic ceramic
metal metal

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6
Q

what ultimately will happen to a hip replacement

A

fail due to loosening or breakdown of the joint replacement components

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7
Q

what can cause a hip replacement to fail

A

wear particles producing an inflammatory response or high stresses (loosening)

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8
Q

what is the risk with metal hip replacements

A

metal particles can cause an inflammatory granuloma (pseudotumour) which can cause muscle and bone necrosis

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9
Q

what can polyethene particles cause

A

an inflammatory response in bone with subsequent bone resorption (osteolysis) resulting in lossening

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10
Q

what is the risk with ceramics

A

can shatter with fatigue due to their brittleness

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11
Q

what are the problems with revision surgeries

A

more difficult
complication rates higher
functional outcomes are poorer
patient satisfaction less

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12
Q

why do younger patients have an increased risk of revision surgery

A

as there is higher demand on the joint replacement

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13
Q

what are the serious complications of joint replacement

A

deep infection, recurrent dislocation, neurovascular injury, pulmonary embolism, medical complications (renal failure, MI, chest infections ect)

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14
Q

what needs to be done if a fulminant infection is diagnosed early after a joint replacement

A

surgical washout, debridement, prolonged parenteral antibiotic therapy

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15
Q

why are infections that last longer than 3 weeks harder to salvage in a joint replacement

A

as infecting bacteria adhere to the foreign surface and grows a biofilm which resists the immune response

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16
Q

what is usually required if there is a deep joint replacement infection for more than 3 weeks

A

removal of implants
left for 6 weeks
given parenteral antibiotics
revision joint replacement once cleared (soft tissues lose elasticity and scar- joint stiffens)

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17
Q

what are the early local complications of a joint replacement

A

Infection, dislocation, instability, fracture, leg length discrepancy, nerve injury, bleeding, arterial injury / ischaemia, bleeding, DVT

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18
Q

what are the early general complications of joint replacements

A

Hypovolaemia, shock, acute renal failure, MI, ARDS, PE, chest infection, urine infection. There is approximately a 0.2% chance of dying as a result of a hip or knee replacement.

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19
Q

what are the late local complications of a joint replacement

A

Infection (from haematogenous spread), loosening, fracture, implant breakage, pseudotumour formation.

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20
Q

what does excision involve and when is it used

A

removal of bone and cartilage of one or both sides of a joint

good for small joints e.g. kellers procedure for hallux valgus

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21
Q

what is arthrodesis

A

surgical stiffening or fusion of a joint in a position of function

remaining hyaline cartilage of the joint and subchondral bone is removed and the joint is stabilised causing bony union and fusion

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22
Q

when is arthrodesis good

A

to relieve pain
end stage ankle arthritis
wrist arthritis
arthritis of the first MTP joint of the foot (hallux rigidus)

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23
Q

what are the negatives of arthrodesis

A 
function may be limited particularly in large joints 
may increase pressure in surrounding joints causing arthritic change
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24
Q

what is an osteotomy

A

surgical re alignment of a bone which can be used to correct deformities or redistribute load across an arthritic joint (shift to an undiseased part)

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25
Q

what tendons can be injected with steroid around the tendon due to risk of rupture

A

achilles, extensor mechanism of knee

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26
Q

what might refractory soft tissue inflammatory problems benefit from

A

surgical debridement or decompression (supraspinatus tendonitis and subacromial decompression)

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27
Q

when can synovectomy be performed

A

for the extensor tendons of the wrist on RA or for inflammation of the tibialis posterior tendon to prevent rupture

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28
Q

what might major tendon tears require (3) (give examples of the the tendons these are done in)

A

splintage (achilles), surgical repair (quadriceps, patellar tendon, sometimes achilles), tendon transfer (tibialis posterior, extensor pollicis longus)

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29
Q

how can meniscal tears be surgically treated

A

with arthroscopic removal (or occasionally repair) if the pain fails to settle or if the cause mechanical symptoms (locking or catching)

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30
Q

how can labral tears of the acetabulum be surgically treated

A

can be resected or repaired

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31
Q

what is instability

A

abnormal motion of a joint (rotation or translation) resulting in subluxation or dislocation with pain and/or giving way

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32
Q

where can you get instability

A

knee (ligament injuries), shoulder, patella, ankle, spine

33
Q

what can cause instability

A

injury, ligamentous laxity, anatomincal variation, underlying disease process (RA, knee hyperextension in polio)

34
Q

how can instability be treated

A

most- physio, splints, calipers, braces

surgery- soft tissues procedures: ligament tightening (ankle)/ advancement (ankle)/ reconstruction using tendon graft (ACL), soft tissue reattachment (shoulder)

bony: fusion (e.g. in cases of severe laxity (ehlers danlos) soft tissue procedures wont work or in spinal instability), osteotomy (skeletal predisposition to dislocation (e.g. patellar instability))

35
Q

what symptoms might spinal instability cause

A

pain, nerve root compression, spinal cord compression

36
Q

what surgery can help nerve compression

A

nerve decompression sugery or discectomy (in spinal nerve root compression- disc material or osteophytes causing a radiculopathy)

37
Q

what can cause joint contractures

A

neuromuscular disease, spasticity (eg stroke), soft tissue imbalance, arthritis, injury, fibrosing disease (Dupuytren’s), disuse or burns

38
Q

how can joint contractures be treated

A

may be passively correctable and may be amenable to splintage, physiotherapy and medications (Baclofen, Botox injections) to relieve spasticity.

Fixed or resistant contractures may require surgical treatment which may consist of tendon lengthening, tendon transfer, release or lengthening of tight soft tissues or bony procedures (osteotomy, arthrodesis).

39
Q

what soft tissue infections involve orthopaedics in their treatment

A

infected bursitis, arm/ leg abscesses, wound infections, joint replacement infection

40
Q

how can organisms infect bone (osteomyelitis)

A

directly penetrating trauma or surgery

indirectly via haemtogenous spread

41
Q

what part of the bone is affected in osteomyelitis

A

can be compact, spongy bone or bone marrow

42
Q

what is the usually type of organisms causing osteomyelitis

A

usually bacteria can be fungal

43
Q

once infected in osteomyelitis, what makes the infection very difficult to eradicate

A

enzymes from leukocytes cause local osteolysis and pus forms which impairs local blood flow

44
Q

what is a sequestrum

A

a dead fragment of bone that can form in osteomyelitis which usually breaks off

45
Q

what happens when a sequestrian is present

A

antibiotics alone will not solve the problem

46
Q

what is an involucrum

A

new bone that forms around the area of necrosis (sequestrian in osteomyelitis)

47
Q

what is an additional feature of staph aureus osteomyelitis that makes it difficult to treat

A

can infect osteocytes intracellularly- harder for immune system to reach

48
Q

who usually gets acute osteomyelitis in the absence of recent surgery

A

children - or immunocomprimised adults

49
Q

why in children can osteomyelitis spread to different parts of the bone

A

the metaphyses of long bones contain abundant tortuous vessels with sluggish flow which can result in accumulation of bacteria and infection spreads towards the epiphysis

50
Q

why is there a risk of septic arthritis in neonates and infants with osteomyelitis

A

certain metaphyses are intra‐articular including the proximal femur, proximal humerus, radial head and ankle and infection can spread into the joint

51
Q

why is there risk of an abscess expanding in infants with osteomyelitis

A

infants have loosely applied periosteum and an abscess can extend widely along the subperiosteal space

52
Q

what is a brodies abcess

A

form of subacute osteomyelitis in children, with insidious onset. bone reacts by walling off the abscess with a thin rim of sclerotic bone

53
Q

what is chronic osteomyelitis

A

develops for an untreated acute osteomyelitis and may be associated with a sequestrum/ involucrum

54
Q

what are features of chronic osteomyelitis

A

tends to be in axial skeleton (spine/ pelvis)
haematogenous spread from pulmonary or urinary infections/ discitis

can be peripheral from previous open fracture or internal fixation

55
Q

what are the symptoms of chronic osteomyelitis

A

is usually suppressed by antibiotics and can lay dormant for many years

when it reactivates- localised pain, inflammation, systemic upset possible sinus formation

56
Q

name an infection that can cause chronic osteomyelitis through haemtogenous spread from the lungs

A

tuberculosis

57
Q

name organisms that commonly cause osteomyelitis in newborns (<4 months)

A

S. Aureus, enterobacter sp., group A and B strep

58
Q

name organisms that commonly cause osteomyelitis in children (4 months to 4 years)

A

S. aureus, group A strep, H. influenzae, enterobacter sp

59
Q

name organisms that commonly cause osteomyelitis in adults

A

S. aureus, enterobacter, streptococcus sp

60
Q

name organisms that commonly cause osteomyelitis in sickle cell anaemia patients

A

S. Aureus, salmonella sp

61
Q

what are the different classifications of osteomyelitis depending on where it affects

A

superficial- outer surface of bone
medullary
localised- cortex and medullary bone
diffuse- segment affected that causes skeletal instability (e.g. infected non union)

62
Q

how is acute osteomyelitis treated

A

by “best guess” antibiotics intravenously unless there is abscess formation which mandates surgical drainage.

If the infection fails to resolve, second line antibiotics may be used or surgery may be performed to gain samples for culture, remove infected bone and washout the infected area.

63
Q

how is chronic osteomyelitis treated

A

cannot be cured or eradicated by antibiotics alone. Active infection can be suppressed with antibiotics

Surgery is usually recommended to gain deep bone tissue cultures, to remove any sequestrum and to excise any infected or non‐ viable bone (debridement)

can also do local antibiotic delivery systems and bone grafting
plastic surgery may be needed

64
Q

what happens if debridement for chronic osteomyelitis causes instability

A

bone must be stabilized by internal or external fixation

65
Q

who is at particular risk of osteomyelitis of the spine

A

Poorly controlled diabetics, intravenous drug abusers and other immunocompromised patients

66
Q

where is the most common location for spine osteomyelitis

A

lumbar spine

67
Q

what is the presentation of spinal osteomyelitis

A

insidious onset of back pain which is constant and unremitting.

They have paraspinal muscle spasm and spinal tenderness and may have fever and/or systemic upset.

Severe cases may have an associated neurologic deficit

Pus may extrude forming a paravertebral or epidural abscess.

As the vertebral end plates weaken, vertebrae may collapse = kyphosis or vertebra plana (flat vertebra) and disc space may reduce

68
Q

what investigations should be done in spinal osteomyelitis

A

MRI- show extent and any abscesses
blood cultures- might show causative organisms
possibly echo- look for endocarditis

69
Q

what is the treatment for osteomyelitis

A

high dose IV antibiotics after CT guided biopsy to get culture
(response monitored via CRP)

half patients go on to spontaneous fusion and resolution

surgery (debridement, stabilisation, vertebra fusion) if no response to antibiotics or worsening condition

70
Q

what role does haematoma play in infection

A

acts as a growth medium

71
Q

what are the features of a chronic deep infection of a prosthetic joint

A

pain, poor function, recurrent sepsis, chronic discharging sinus formation, implant loosening

72
Q

what is the risk of a deep infection in fracture fixation or stabilisation

A

chronic osteomyelitis and non union of the fracture

73
Q

what organisms produce an early prosthetic infection

A

s aureus, gram negative bacilli (inc coliforms)

74
Q

what organisms cause low grade prosthetic infection that is often diagnosed late (often requires surgical intervention)

A

Staph. epidermidis (also known as coagulase negative staphylococci) and enterococcus

75
Q

what organisms cause late onset prosthetic infection associated with late onset haemotogenous infection

A

Staph. aureus, beta haemolytic Streptococcus and Enterobacter.

76
Q

what is the treatment for prosthetic joint infection

A

usually surgical

antibiotics not given immediatley as may interfere with cultures

77
Q

can pseudotumours be locally invasive

A

yes

78
Q

True or false: A tibial osteotomy may be considered as an alternative surgical option to joint replacement for knee arthritis in the young patient.

A

true

MSK (71 decks)

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