Management of Arthritic Joint Flashcards
arthroplasty
in general terms is synonymous with joint replacement
also used to describe removal of diseased joint (excision or resection arthroplasty)
(pic is THR)
what is joint replacement of half/whole joint called
hemiarthroplasty
total joint replacement
what are the most successful joint replacements
hip and knee
- good function, satisfactory pain relief and last a reasonable length of time
also glenohumeral joint, elbow, ankle, 1MTP, MCP
what can joint replacements be made from
stainless steel, cobalt chrome, titanium alloy, polyethylene and ceramic
no single ideal material/combination of materials
how will a joint replacement ultimately fail
will ultimately fail due to loosening (wear particles producing an inflammatory response or high stresses) or breakage of components
what can metal particles produce
pseudotumour (inflammatory granuloma) which can cause muscle and bone necrosis
what can polyethylene particles produce
inflammatory response in bone with subsequent bone resorption by osteoclasts (osteolysis) resulting in loosening
what can ceramics cause
can shatter with fatigue due to their brittleness
compare a revision procedure to a primary one
higher complication rate
poorer functional outcome
lower patient satisfaction
how do JR usually fare in younger patients
in general the younger the patient, the higher the demand on the JR and the higher the likelihood of failure
what are some serious complications of JR
deep infection, recurrent dislocation, PE, neurovascular injury, medical complications (renal failure, MI, chest infection)
how is a deep infection after JR managed if diagnosed within the first 2-3 weeks
surgical washout and debridement and prolonged parenteral antibiotic therapy (6 weeks) to attempt to salvage the joint
50% success rate
how is a deep infection after JR managed if present for >3 weeks
tend not to be salvageable as infecting bacteria adhere to foreign surface and form a biofilm which prevents the patients immune system attacking
remove all foreign material (requires extensive surgery)
patient left without joint for 6 weeks and given parenteral antibiotics
once infection is under control a revision JR is performed
80-90% successful, however throughout the process soft tissue scar and lose elasticity - joint stiffens and overal functional outcomes is usually compromised
early local complications of JR
Infection, dislocation, instability, fracture, leg length discrepancy, nerve injury, bleeding, arterial injury / ischaemia, bleeding, DVT.
early general complications of JR
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.
late local complications of JR
infection (from haematogenous spread), loosening, fracture, implant breakage, pseudotumour formation
excision/resection arthroplasty
removal of bone/cartilage on one or both sides of a joint
more effective for smaller joints (eg Keller’s procedure for Hallux Rigidus)
occasionally used after failure of hip or shoulder replacement
arthrodesis
surgical stiffening/fusion of joint in position of function
function may be limited, particularly in large joints, and may increase pressure in surrounding joints leading to arthritic change
what is arthrodesis good for
end stage ankle arthritis, wrist arthritis and hallux rigidus
what is the gold standard treatment for hallux rigidus
arthrodesis
osteotomy
surgical realigment of bone (by cutting it) which can be used for deformity correction or to redistribute load across an arthritic joint
can be used for early arthritis of knee and hip
effect of quinolone antibtioics on tendons
increase risk of tendonitis and tendon rupture
how are most soft tissue inflammatory problems managed
rest, analgesia and anti-inflammatory
injection of steroid (tennis elbow, rotator cuff)
(NOT achilles or extensor knee mechanism)
what may refractory soft tissue problems benefit from
surgical debridement or decompression (making more space eg supraspinatus tendon and subacromial decompression)
synovectomy (eg extensor tendon in wrist in RA or tibialis posterior inflammation to prevent rupture)
what may major tendon tears require
splintage (achilles), surgical repair (quadriceps/patellar) or tendon transfer (tibialis posterior, extensor pollicus longus)
how can meniscal tears in the knee be treated
arthroscopic removal
- only have arterial blood supply on the outer third so have limited healing potential - only consider this in acute peripheral tears in YP
joint instability
abnormal motion of a joint resulting in subluxation or dislocation with pain/giving way
commonly, due toknee ligament injuries, of shoulder, patella, ankle instability
what can cause joint instability
consequence of injury
ligamentous laxity
prediposed by anatomical variaiton
underlying disease process
what can cause cervical spine instability in RA
involvement of C1 and C2 - subluxation - cervical cord compression
how can may cases of joint instability be managed
physiotherapy to strengthen surrounding muscles and improve proprioception
splints, calipers, braces may provide additional support
what soft tissue procedures are used for joint instability
ligament tightening/advancement
ligament reconstruction using tendon graft (ACL reconstruction - rule of thirds)
soft tissue reattachment
in cases of significant ligamentous laxity causing joint instability what procedures are used
eg EhD
bony procedure (eg fusion) as soft tissue are unlikely to work
in cases of joint instability where there is a skeletal predisposition to dislocation what procedure is used
osteotomy
what may spinal instability require
can cause pain (radiculopathy), nerve root compression or spinal cord compression
fusion of abnormal spinal segment
what is surgery used for in scoliosis
mild cases dont require surgery
severe cases can use surgery for cosmesis or to improve wheelchair sitting
severe scoliosis causes restrictive lung defects and surgery may be required to prevent breathing difficulties
what is sometimes the best treatment for congenital malformations
amputation - complex surgery required otherwise
what may angular deformity of long bones of lower limb result in
early arthritis of knee/ankle due to abnormal distribution of force - growth plate manipulation/osteotomy
what technique can be used for leg length discrepancies
shorten/lengthen limb appropriately
what is the main indication for arthroplasty/joint replacment in an arthritic joint
pain
