Elective Surgery Flashcards
when is surgical management considered in MSK referrals?
if there is an appropriate surgical solution conservative measures have not controlled symptoms surgical intervention more appropriate (e.g. tumour)
the decision to undertake surgery is based on
- the underlying condition - the prognosis without surgical intervention - degree of symptoms the patient is experiencing- disability caused by the condition - status of the patient’s health
what needs to happen through consultation for surgery to take place?
appropriate consenting explanation of risks & benefits explanation of the alternatives to surgery
what conditions are common orthopaedic surgical elective procedures used to manage?
Arthritis soft tissue inflammatory problems Tendonitis Tendon rupture Correction of deformity Nerve decompression Joint instability Joint contractures Chronic infection Tumour diagnosis and treatment
what is arthroplasty?
reshaping of a joint general term - synonymous with joint replacement can also be used to describe the removal of a diseased joint - excision/resection arthroplasty
what is a joint replacement?
replacement of part of the joint - hemiarthroplasty replacement of the whole joint - total joint replacement
What are the most successful joint replacements?
hip and knee
-good function satisfactory
-pain relief
-last a reasonable length of time
-complication rates are low
what other joints can be replaced other than hip and knee?
shoulder (glenohumeral)
elbow
ankle
1st MTP joint of the great toe
MCP joints of the hand and wrist
What are joint replacements made of?
Stainless steel Cobalt Chrome Titanium ally polyetylene Ceramic The components can be - cemented and uncemented
what is the prognosis of joint replacements?
no perfect joint replacement
Could fail due to - loosening
(wear particles produce inflammatory response, high stresses)-
Breakage of the joint replacement Components metal particles can cause an inflammatory granuloma (pseudotumour)
- Muscle and bone necrosis
- Polyethylene particles can cause inflammatory response in bone with bone resorption (osteolysis)
- Loosening ceramics can shatter with fatigue
what is a revision procedure?
remove old components & insert a new replacementmuch more difficult than first procedurecomplication rates higherfunctional outcomes poorerpatient satisfaction is less
what kind of patient is more likely to have an early joint replacement failure?
younger patient higher demand on the JR makes there a higher likelihood
what are the potential complications of a joint replacement?
Deep infection
Recurrent dislocation
Neurovascular injury
Pulmonary embolism
Medical complications -renal failure, MI, chest infections
what is done to prevent deep infections in JR?
strict aseptic and aseptic precautions
what to do if a deep infection in a JR is diagnosed within 2-3 weeks?
surgical washout and debridement and prolonged antibiotic therapy about 6 weeks 50% success
what to do if a deep infection following a JR is present for longer than 3 weeks - not salvageable by washout?
- bacteria adhere to foreign surfaces
– Biofilm- prevent patient’s immune system attacking - Remove implant & all foreign material (cement)
extensive surgery, without a joint for about 6 weeks, parenteral antibiotics, if infection under control = wound healed clean & dry, CRP reduced
– Revision replacement
80-90% success, soft tissues scar & lose elasticity, joint stiffens, overall functional outcome compromised
early complications of a joint replacement?
-Infection
-Dislocation
-Instability
-Fracture
-Leg length discrepancy
-Nerve injury
-Bleeding
-Arterial injury/ischaemia
-Bleeding
-DVT
early general complications of a JR?
-Hypovolaemia
-Acute renal failure
-MI
-ARDS
-PE
-Chest infection
-Urine infection
late local complications of a JR?
o infection – from hemategoneous spread
o loosening
o fracture
o implant breakage
o pseudotumuor formation
what is an excision/ resection arthroplasty?
removal of bone and cartilage of one or both sides of a jointdisabling for longer joint - 1st surgical procedure for hip OA
indications for a excision/ resections arthroplasty?
Effective for smaller joint
1st carpometacarpal joint in hand
Keller’s procedure for hallux valgus after failure of hip/ shoulder replacement
What is arthrodesis?
surgical stiffening/ fusion of a joint in a position of function hyaline cartilage and subchondral bone removed
- joint stabilized
- bony union and fusion
What is the affect of arthrodesis?
alleviates pain function may be limited particularly in large joints may increase pressure in surrounding joints - OA
what are the indications for arthrodesis?
end stage ankle arthritis
wrist arthritis
arthritis of 1st MTP of the foot (hallux rigidus)
what is an osteotomy?
surgical realignment of a bone deformity correction
What is the purpose of osteotomy?
to redistribute load across an arthritic joint
-Offload diseased part of the joint
-Shift load to undiseased part e.g. medial compartment of the knee to the lateral compartment
what are the indications for osteotomy?
early arthritis in the knee early arthritis in the hip
what are some common soft tissue problems?
- Tendinopathies = tears & ruptures- Enthesopathies = inflammation of a tendinous origin from / insertion into bone- Cartilage tears- Labrum tears- Inflammatory bursitis- Tenosynovitis- Capsulitis- Non-infective fasciitis
what can soft tissue problems be related to?
degenerative processes injuries overuse inflammatory conditions – RAdrugs – quinolone antibiotics, steroids chronic disease – renal failure idiopathic
what is the conservative treatment for soft tissue problems?
conservative treatment is often very effective rest analgesia anti-inflammatory medications
what tendons and entheses are amenable to steroid injection around tendon?
rotator cuff tennis elbow
which tendons have a high risk of rupture so are not advised for steroid injection
achilles extensor mechanism of the knee
what is debridement?
removal of diseased tissue
what is decompression?
making more space - supraspinatus tendonitis and subacromial decompression
what is a synovectomy?
extensor tendons of the wrist in RA inflammation of tibialis posterior to prevent rupture
Examples of major tendon tears
splintage-Achilles
Surgical repair –quadriceps / patellar tendon (sometimes Achilles)
Tendon transfer – tibialis posterior, extensor pollicis longus
what are the indications of a cartilage (meniscal) tear in the knee?
pain fails to settlecause mechanical symptoms (locking or catching)
what is the management of a labral tear of the acetabulum or glenoid
resection/repair
what is joint instability?
abnormal motion of a joint (rotation/translation)resulting in:subluxation dislocation with pain and/or giving away
common examples of joint instability
- instability from knee
- ligament injuries
- recurrent subluxation of the shoulder
- recurrent dislocation of the shoulder
- recurrent subluxation of the patella
- recurrent dislocation of the patella
- ankle instability with frequent giving away
- spinal instability
what causes instability?
- injury
- ligamentous laxity
- anatomic variation predisposing:
- shallow trochlea of distal femuro femoral neck anteversion
- o genu valgum in patellofemoral instability
- underlying disease process
- cervical spine instability in rheumatoid arthritis
- knee hyperextension in polio
what is the conservative treatment for joint instability?
-physiotherapy
-improve proprioception
-splints
-calipers
-braces
what are the surgical soft tissue procedures?
ligament tightening / advancement – e.g. ankle instability
ligament reconstruction using tendon graft – e.g. ACL reconstruction
Tissue reattachment – shoulder instability
Significant ligament laxity (EDS) – soft tissue procedures are highly unlikely to work
what are the surgical bony procedures for joint instability?
FUSION: in significant ligament laxity (EDS) where soft tissue doesn’t work –
Skeletal predisposition to dislocation (eg patellar instability) –
Osteotomy: spinal instability: pain, nerve root compression/
spinal cord compression – fusion of abnormal spinal motion segment
what is the purpose of correcting a deformity?
improve function prevent arthritis improve cosmesis
what causes deformity?
congenital – limb malformationdevelopmental – bow legsacquired – post-traumaticidiopathic – hallux valgus, claw toes
what is the management of congenital deformity?
may require complex bony and soft tissue surgery restore as much function as possible some best served by functional amputation
management of angular deformity of long bones of the lower limb?
this can lead to early arthritis of the knee/ankle growth plate manipulation surgery osteotomy
management options for leg length discrepancies?
shortening the longer limb
lengthening the short limb using special external fixator = llizarov technique
management options for foot deformities?
these can give rise to pressure problems with footwear osteotomy arthrodesis soft tissue procedures joint excisions
why is surgery done for spine deformities?
cosmesis
improve wheelchair sitting
severe scoliosis - restrictive respiratory defect - correction to prevent this
most common sites of peripheral nerve trapping?
median nerve at the wrist = carpal tunnel syndrome
Ulnar nerve at the elbow = cubital tunnel syndrome
how is peripheral nerve trapping treated?
nerve decompression surgery
what causes spinal nerve compression?
disc material
bony osteophytes causes radiculopathy
how is spinal nerve compression treated?
spinal decompression/discectomy
what causes joint contractures?
neuromuscular disease
spasticity – eg. strokesoft tissue imbalance
arthritis
injury
fibrosing disease (Dupuytren’s)disease burns
what is a joint contracture?
an inability to move a joint through its full range of motion
what is the conservative treatment for joint contractures?
passively correctable & may be amenable
splintage
physiotherapy medications – Baclofen,
Botox injections – to relieve spasticity
what is the surgical treatment options for joint contractures?
Fixed or resistant contractures
Tendon lengthening
Tendon transfer
Tight soft tissue release or lengthening
Bony procedures: osteotomy, arthrodesis
what are the types of infections orthopaedics are involved in?
Soft tissue infections e.g. infected bursitis, arm or leg abscesses,
Wound infections - if abscess might need surgery
Bone infection
Joint infection: septic arthritis - emergency
what is osteomyelitis?
infection of the bone including - compact bone, spongy bone and bone marrow
levels of ostomyelitis?
superficial - affecting the outer surface of bone
Localized - affecting cortex and medullary
Diffuse - segment of bone is infected resulting in skeletal instability - infected non-union
what causes the infection to reach the bone?
direct infection - penetrating trauma or surgery
Indirect infection - haematogenous spread from an infection, bacteremia at a distant site (area of cellulitis)
what is involucrum?
new bone formed around the area of necrosis
what are the factors which an infection depends on?
bacterial load
Inoculated virulence of the organism
Host’s immune defenses
what is the pathogenesis of osteomyelitis once the bone is infected?
there are enzymes from the leukocytes which cause local osteolysis and pus there is impaired local blood flow - infection is difficult to eradicate
what makes staph aureus such a bad infection?
it can infect the osteocytes intracellularly - which makes it very hard for the immune system to reach
what is a sequestrum?
a dead fragment of bone which normally breaks off - once there is a sequestrum present then antibiotics won’t be enough
who gets osteomyelitis?
immunocompromised patients
Chronic disease
Elderly
Young
what bacteria cause osteomyelitis in newborns (less than 4 months)?
S. aureus
Enterobacter sp.
Group A & B Strep
what bacteria cause osteomyelitis in children (4 months to 4 years)?
S. aureus
Group A strep
Haemophilus influenzae - reduced by vaccine
Enterobacter sp.
what bacteria cause osteomyelitis in children/ adolescents (4 - adult)
S aureus (80%)
Group A strep
H influenzae
Enterobacter sp.
What bacteria cause osteomyelitis in adults?
S. aureus and occasionally Enterobacter or Streptococcus sp.
what bacteria cause osteomyelitis in sickle cell patients?
S. aureus - most common
Salmonella:common as well
what causes acute osteomyelitis?
surgery
If no surgery has happened, it can occur in children/ immunocompromised without surgery
what is the pathogenesis of acute osteomyelitis in children?
Metaphyses of long bones get tortuous vessels
> this causes sluggish flow accumulation of bacteria infection spreads towards the epiphysis
what is the pathogenesis of acute osteomyelitis in neonates and infants?
Certain metaphyses are intra-articular (proximal femur, proximal humerus, radial head, ankle) > infection here can spread into the joint co-existing septic arthritis
(infants have a loosely applied periosteum so an abscess can extend widely along the subperiosteal space)
What is a Brodie’s abscess?
Subacute osteomyelitis with a more insidious onset -
Bone reacts with walling off the abscess with a thin rim of sclerotic bone
How is acute osteomyelitis managed?
best guess antibiotics by IV if abscess then surgical drainage If the infection fails to resolve then
- 2nd line antibiotics
- Surgery
- Gain samples for culture, remove infected bone, washout infected area
who gets chronic osteomyelitis?
Untreated acute osteomyelitis
-Sequestrum and/or involucrum adults in the axial skeleton because of haematogenous spread from pulmonary/urinary infection or from infection of IV disc (discitis)
Peripheral skeleton
- Open fracture or fixation
-TB
-Chronic osteomyelitis from haematogenous spread from the primary lung infection
What is the pathogenesis of chronic osteomyelitis?
can be suppressed with antibiotics can lay dormant for many years before reactivating
what are the signs and symptoms of chronic osteomyelitis?
Localized pain
Inflammation
Systemic upset
Possible sinus formation
how is chronic osteomyelitis managed?
Cannot be cured by just antibiotics
-Active infection - can be suppressed by antibiotics
- Surgery - gain deep bone tissue cultures - remove sequestrum
- Excise infected or non-viable bone = debridement
- Samples from discharging sinus may not accurately reflect the organism causing deep infection
External fixation - might be needed is to lengthen the bone if debridement shortens it
Local antibiotic delivery systems bone grafting plastic surgery
-If skin and soft tissue coverage of the bone isn’t possible IV antibiotics for several weeks following surgery
who gets osteomyelitis of the spine?
Poorly controlled diabetics
IV drug abusers
Immunocompromised patients
What is the pathogenesis of osteomyelitis in the spine?
Lumbar spine is most common can complicate spinal surgery
-If below LI:
- lower motor neurone, cauda equina below
- If above LI: upper motor neurone, myelopathy
Pus may extrude - paravertebral/ epidural abscessvertebral end plates weaken
- The vertebrae might collapse
- Kyphosis
- Vertebra plana (flat)- disc space may reduce
what are the signs and symptoms of osteomyelitis of the spine?
Insidious onset of back pain
Constant and unremitting pain
Paraspinal muscle spasm
Spinal tenderness
Fever
Systemic upset if severe (neurologic deficit) -
Below LI - lower motor neurone, cauda equina syndrome
Above LI - upper motor neurone, myelopathy kyphosis
what investigations would you do for suspected osteomyelitis of the spine?
MRI - shows extent of infection and abscess formation
FBC- for causative organism (S. aureus, MRSA, atypical)
Endocarditis should be considered - clubbing splinter haemorrhages, murmur, ECHO
how is osteomyelitis of the spine managed?
CT guided biopsy to obtain tissue cultures
High dose IV antibiotics -may be for several months
Response assessed - clinically,
Serial CRP
50% go on to spontaneous fusion and resolution surgery -
debridement -
stabilization - fusion of adjacent vertebrae
what are the indications for surgery in the treatment for osteomyelitis of the spine?
Inability to obtain cultures by needle biopsy
No response to antibiotic therapy
Progressive vertebral collapse
Progressive neurological deficit
what are some common orthopaedic implants?
Joint replacements - for arthritis, instability and tumour
Surgery:fracture fixation and skeletal stabilization
Pins, wires, plates screws
Intramedullary nails external fixators
what precautions are taken to prevent infection of orthopaedic surgical implants?
Strict antisepsis
Sterilisation of implants and instruments
Special air flow theatres
Perioperative antibiotics
how common is deep infection in non-contaminated orthopaedic procedures?
1-2%
how do bacteria enter to cause infection of orthopaedic surgical implants?
Operative site at the time of surgery
- Patient’s own skin and bacteria deep within hair follicles and from shed skin cell from staff in theatre
- Wound post-operatively before it has healed
- Haematoma
- In soft tissues, bacteria thrive on can also infect prosthetic joint at a later stage by haematogenous spread
what are the signs that a chronic infection has developed post prosthetic joint replacement complicating it?
Pain
Poor function
Recurrent sepsis
Chronic discharging sinus formation
Implant loosening
What happens when a deep infection complicates a fracture fixation or stabilization?
chronic osteomyelitis
Non-union of the fracture
what organisms cause an infection of orthopaedic surgical implants?
Staph aureus
Gram -ve bacilli: coliforms
Staph epidermidis
Enterococcus
Late onset haematogenous infection
- staph aureus
- beta haemolytic strep. - enterobacter
how is an infection of an orthopaedic surgical implant treated?
Usually surgical rather than antibiotics
Antibiotics - not given until there’s a decision made about surgery (any AB can interfere with the bacteriological tissue cultures and causative organism may not be identified from debridement)
