Elective Surgery Flashcards
1
Q
when is surgical management considered in MSK referrals?
A
if there is
an appropriate surgical solution
conservative measures have not controlled symptoms
surgical intervention more appropriate (e.g. tumour)
2
Q
the decision to undertake surgery is based on
A
- 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
3
Q
what needs to happen through consultation for surgery to take place?
A
appropriate consenting
explanation of risks & benefits
explanation of the alternatives to surgery
4
Q
what conditions are common orthopaedic surgical elective procedures used to manage?
A
arthritis soft tissue inflammatory problems - tendonitis, tendon rupture correction of deformity nerve decompression joint instability joint contractures chronic infection tumour diagnosis and treatment
5
Q
what is arthroplasty?
A
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
6
Q
what is a joint replacement?
A
replacement of part of the joint - hemiarthroplasty
replacement of the whole joint - total joint replacement
7
Q
What are the most successful joint replacements?
A
hip and knee good function satisfactory pain relief last a reasonable length of time complication rates are low
8
Q
what other joints can be replaced other than hip and knee?
A
shoulder (glenohumeral) elbow ankle 1st MTP joint of the great toe MCP joints of the hand and wrist
9
Q
What are joint replacements made of?
A
stainless steel cobalt chrome titanium ally polyetylene ceramic the components can be - cemented and uncemented
10
Q
what is the prognosis of joint replacements?
A
no perfect joint replacement
will fail due to
- loosening (wear particles produce inflammatory response, high stresses)
- breakage of the joint replacement components
metal particles - cause an inflammatory granuloma (pseudotumour)
- muscle and bone necrosis
polyethylene particles - inflammatory response in bone with bone resorption (osteolysis) - loosening
ceramics can shatter with fatigue - due to brittleness
11
Q
what is a revision procedure?
A
remove old components & insert a new replacement much more difficult than first procedure complication rates higher functional outcomes poorer patient satisfaction is less
12
Q
what kind of patient is more likely to have an early joint replacement failure?
A
younger patient
higher demand on the JR makes there a higher likelihood
13
Q
what are the potential complications of a joint replacement?
A
deep infection recurrent dislocation neurovascular injury pulmonary embolism medical complications - renal failure, MI, chest infections
14
Q
what is done to prevent deep infections in JR?
A
strict aseptic and aseptic precautions
15
Q
what to do if a deep infection in a JR is diagnosed within 2-3 weeks?
A
surgical washout and debridement and prolonged antibiotic therapy
about 6 weeks
50% success
16
Q
what to do if a deep infection following a JR is present for longer than 3 weeks - not salvageable by washout?
A
- 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
17
Q
early complications of a joint replacement?
A
o infection o dislocation o instability o fracture o leg length discrepancy o nerve injury o bleeding o arterial injury/ischaemia o bleeding o DVT
18
Q
early general complications of a JR?
A
o hypovolaemia o shock o acute renal failure o MI o ARDS o PE o chest infection o urine infection
19
Q
late local complications of a JR?
A
o infection – from hemategoneous spread o loosening o fracture o implant breakage o pseudotumuor formation
20
Q
what is an excision/ resection arthroplasty?
A
removal of bone and cartilage of one or both sides of a joint
disabling for longer joint - 1st surgical procedure for hip OA
21
Q
indications for a excision/ resections arthroplasty?
A
effective for smaller joint
1st carpometacarpal joint in hand
Keller’s procedure for hallux valgus
after failure of hip/ shoulder replacement
22
Q
What is arthrodesis?
A
surgical stiffening/ fusion of a joint in a position of function
hyaline cartilage and subchondral bone removed - joint stabilized - bony union and fusion
23
Q
What is the affect of arthrodesis?
A
alleviates pain function may be limited particularly in large joints may increase pressure in surrounding joints - OA
24
Q
what are the indications for arthrodesis?
A
end stage ankle arthritis
wrist arthritis
arthritis of 1st MTP of the foot (hallux rigidus)
25
what is an osteotomy?
surgical realignment of a bone
| deformity correction
26
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
27
what are the indications for osteotomy?
early arthritis in the knee
| early arthritis in the hip
28
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
29
what can soft tissue problems be related to?
```
degenerative processes
injuries
overuse
inflammatory conditions – RA
drugs – quinolone antibiotics, steroids
chronic disease – renal failure
idiopathic
```
30
what is the conservative treatment for soft tissue problems?
conservative treatment is often very effective
rest
analgesia
anti-inflammatory medications
31
what tendons and entheses are amenable to steroid injection around tendon?
rotator cuff
| tennis elbow
32
which tendons have a high risk of rupture so are not advised for steroid injection
achilles
| extensor mechanism of the knee
33
what is debridement?
removal of diseased tissue
34
what is decompression?
making more space - supraspinatus tendonitis and subacromial decompression
35
what is a synovectomy?
extensor tendons of the wrist in RA
| inflammation of tibialis posterior to prevent rupture
36
Examples of major tendon tears
splintage – Achilles
surgical repair – quadriceps / patellar tendon (sometimes Achilles)
tendon transfer – tibialis posterior, extensor pollicis longus
37
what are the indications of a cartilage (meniscal) tear in the knee?
pain fails to settle
| cause mechanical symptoms (locking or catching)
38
what is the management of a labral tear of the acetabulum or glenoid
resection/repair
39
what is joint instability?
abnormal motion of a joint (rotation/translation)
resulting in:
subluxation
dislocation with pain and/or giving away
40
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
41
what causes instability?
- injury
- ligamentous laxity
- anatomic variation predisposing:
o shallow trochlea of distal femur
o femoral neck anteversion
o genu valgum in patellofemoral instability
- underlying disease process
o cervical spine instability in rheumatoid arthritis
o knee hyperextension in polio
42
what is the conservative treatment for joint instability?
```
physiotherapy
- strengthen up surrounding muscles
- improve proprioception
e.g. ACL rupture, ankle & shoulder instability
splints
calipers
braces
```
43
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
44
what are the surgical bony procedures for joint instability?
in significant ligament laxity (EDS) where soft tissue doesn’t work – e.g. fusion
skeletal predisposition to dislocation (eg patellar instability) – osteotomy
spinal instability: pain, nerve root compression/ spinal cord compression – fusion of abnormal spinal motion segment
45
what is the purpose of correcting a deformity?
improve function
prevent arthritis
improve cosmesis
46
what causes deformity?
congenital – limb malformation
developmental – bow legs
acquired – post-traumatic
idiopathic – hallux valgus, claw toes
47
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
48
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
49
management options for leg length discrepancies?
shortening the longer limb
lengthening the short limb
using special external fixator = llizarov technique
50
management options for foot deformities?
```
these can give rise to pressure problems with footwear
osteotomy
arthrodesis
soft tissue procedures
joint excisions
```
51
why is surgery done for spine deformities?
cosmesis
improve wheelchair sitting
severe scoliosis - restrictive respiratory defect - correction to prevent this
52
most common sites of peripheral nerve trapping?
median nerve at the wrist = carpal tunnel syndrome
| ulnar nerve at the elbow = cubital tunnel syndrome
53
how is peripheral nerve trapping treated?
nerve decompression surgery
54
what causes spinal nerve compression?
disc material
bony osteophytes
causes radiculopathy
55
how is spinal nerve compression treated?
spinal decompression/discectomy
56
what causes joint contractures?
```
neuromuscular disease
spasticity – eg. stroke
soft tissue imbalance
arthritis
injury
fibrosing disease (Dupuytren’s)
disease
burns
```
57
what is a joint contracture?
an inability to move a joint through its full range of motion
58
what is the conservative treatment for joint contractures?
passively correctable & may be amenable
splintage
physiotherapy
medications – Baclofen, Botox injections – to relieve spasticity
59
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
```
60
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
61
what is osteomyelitis?
infection of the bone including - compact bone, spongy bone and bone marrow
62
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
63
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)
64
what is involucrum?
new bone formed around the area of necrosis
65
what are the factors which an infection depends on?
bacterial load inoculated
virulence of the organism
host's immune defenses
66
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
67
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
68
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
69
who gets osteomyelitis?
immunocompromised patients
chronic disease
elderly
young
70
what bacteria cause osteomyelitis in newborns (less than 4 months)?
S. aureus
Enterobacter sp.
group A & B Strep
71
what bacteria cause osteomyelitis in children (4 months to 4 years)?
S. aureus
group A strep
Haemophilus influenzae - reduced by vaccine
Enterobacter sp.
72
what bacteria cause osteomyelitis in children/ adolescents (4 - adult)
S aureus (80%)
group A strep
H influenzae
Enterobacter sp.
73
What bacteria cause osteomyelitis in adults?
S. aureus
and occasionally
Enterobacter or Streptococcus sp.
74
what bacteria cause osteomyelitis in sickle cell patients?
S. aureus - most common
| Salmonella species are common as well though and only really happen in sickle cell patients
75
what causes acute osteomyelitis?
surgery
| if no surgery can occur in children or immunocompromised without surgery trigger
76
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
77
what is the pathogenesis of acute osteomyelitis in neonates and infants?
certain metaphyses are intra-articular like the proximal femur, proximal humerus, radial head, ankle etc.
infection here can spread into the joint
co-existing septic arthritis
(infants have aa loosely applied periosteum so an abscess can extend widely along the subperiosteal space)
78
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
79
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
```
80
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
81
What is the pathogenesis of chronic osteomyelitis?
can be suppressed with antibiotics
| can lay dormant for many years before reactivating
82
what are the signs and symptoms of chronic osteomyelitis?
localized pain
inflammation
systemic upset
possible sinus formation
83
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
84
who gets osteomyelitis of the spine?
poorly controlled diabetics
IV drug abusers
immunocompromised patients
85
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 abscess
vertebral end plates weaken - the vertebrae might collapse
- kyphosis
- vertebra plana (flat)
- disc space may reduce
86
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
```
87
what investigations would you do for suspected osteomyelitis of the spine?
MRI - delineates the extent of infection and abscess formation
Blood - may indicate causative organism (S. aureus, MRSA, also atypical)
Endocarditis should be considered - clubbing splinter haemorrhages, murmur, ECHO
88
how is osteomyelitis of the spine managed?
CT guided biopsy to obtain tissue cultures
High dose IV antibiotics - 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
89
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
90
what are some common orthopaedic implants?
```
joint replacements - for arthritis, instability and tumour surgery
for fracture fixation and skeletal stabilization
pins
wires
plates
screws
intramedullary nails
external fixators
```
91
what precautions are taken to prevent infection of orthopaedic surgical implants?
strict antisepsis
sterilisation of implants and instruments
special air flow theatres
perioperative antibiotics
92
how common is deep infection in non-contaminated orthopaedic procedures?
1-2%
93
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
94
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
```
95
What happens when a deep infection complicates a fracture fixation or stabilization?
chronic osteomyelitis
| non-union of the fracture
96
what organisms cause an infection of orthopaedic surgical implants?
```
staph aureus
gram -ve bacilli - including coliforms
more indolent - low grade, diagnosed late (2 years after surgery) requires surgery
- staph epidermidis
- enterococcus
late onset haematogenous infection
- staph aureus
- beta haemolytic strep.
- enterobacter
```
97
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 antibiotics can interfere with the bacteriological tissue cultures and causative organism may not be identified from debridement
