Management of Arthritic Joint

Question 1

arthroplasty

Answer 1

in general terms is synonymous with joint replacement

also used to describe removal of diseased joint (excision or resection arthroplasty)

(pic is THR)

Question 2

what is joint replacement of half/whole joint called

Answer 2

hemiarthroplasty

total joint replacement

Question 3

what are the most successful joint replacements

Answer 3

hip and knee

• good function, satisfactory pain relief and last a reasonable length of time

also glenohumeral joint, elbow, ankle, 1MTP, MCP

Question 4

what can joint replacements be made from

Answer 4

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

no single ideal material/combination of materials

Question 5

how will a joint replacement ultimately fail

Answer 5

will ultimately fail due to loosening (wear particles producing an inflammatory response or high stresses) or breakage of components

Question 6

what can metal particles produce

Answer 6

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

Question 7

what can polyethylene particles produce

Answer 7

inflammatory response in bone with subsequent bone resorption by osteoclasts (osteolysis) resulting in loosening

Question 8

what can ceramics cause

Answer 8

can shatter with fatigue due to their brittleness

Question 9

compare a revision procedure to a primary one

Answer 9

higher complication rate

poorer functional outcome

lower patient satisfaction

Question 10

how do JR usually fare in younger patients

Answer 10

in general the younger the patient, the higher the demand on the JR and the higher the likelihood of failure

Question 11

what are some serious complications of JR

Answer 11

deep infection, recurrent dislocation, PE, neurovascular injury, medical complications (renal failure, MI, chest infection)

Question 12

how is a deep infection after JR managed if diagnosed within the first 2-3 weeks

Answer 12

surgical washout and debridement and prolonged parenteral antibiotic therapy (6 weeks) to attempt to salvage the joint

50% success rate

Question 13

how is a deep infection after JR managed if present for >3 weeks

Answer 13

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

Question 14

early local complications of JR

Answer 14

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

Question 15

early general complications of JR

Answer 15

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.

Question 16

late local complications of JR

Answer 16

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

Question 17

excision/resection arthroplasty

Answer 17

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

Question 18

arthrodesis

Answer 18

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

Question 19

what is arthrodesis good for

Answer 19

end stage ankle arthritis, wrist arthritis and hallux rigidus

Question 20

what is the gold standard treatment for hallux rigidus

Answer 20

arthrodesis

Question 21

osteotomy

Answer 21

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

Question 22

effect of quinolone antibtioics on tendons

Answer 22

increase risk of tendonitis and tendon rupture

Question 23

how are most soft tissue inflammatory problems managed

Answer 23

rest, analgesia and anti-inflammatory

injection of steroid (tennis elbow, rotator cuff)

(NOT achilles or extensor knee mechanism)

Question 24

what may refractory soft tissue problems benefit from

Answer 24

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)

Question 25

what may major tendon tears require

Answer 25

splintage (achilles), surgical repair (quadriceps/patellar) or tendon transfer (tibialis posterior, extensor pollicus longus)

Question 26

how can meniscal tears in the knee be treated

Answer 26

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

Question 27

joint instability

Answer 27

abnormal motion of a joint resulting in subluxation or dislocation with pain/giving way

commonly, due toknee ligament injuries, of shoulder, patella, ankle instability

Question 28

what can cause joint instability

Answer 28

consequence of injury

ligamentous laxity

prediposed by anatomical variaiton

underlying disease process

Question 29

what can cause cervical spine instability in RA

Answer 29

involvement of C1 and C2 - subluxation - cervical cord compression

Question 30

how can may cases of joint instability be managed

Answer 30

physiotherapy to strengthen surrounding muscles and improve proprioception

splints, calipers, braces may provide additional support

Question 31

what soft tissue procedures are used for joint instability

Answer 31

ligament tightening/advancement

ligament reconstruction using tendon graft (ACL reconstruction - rule of thirds)

soft tissue reattachment

Question 32

in cases of significant ligamentous laxity causing joint instability what procedures are used

Answer 32

eg EhD

bony procedure (eg fusion) as soft tissue are unlikely to work

Question 33

in cases of joint instability where there is a skeletal predisposition to dislocation what procedure is used

Answer 33

osteotomy

Question 34

what may spinal instability require

Answer 34

can cause pain (radiculopathy), nerve root compression or spinal cord compression

fusion of abnormal spinal segment

Question 35

what is surgery used for in scoliosis

Answer 35

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

Question 36

what is sometimes the best treatment for congenital malformations

Answer 36

amputation - complex surgery required otherwise

Question 37

what may angular deformity of long bones of lower limb result in

Answer 37

early arthritis of knee/ankle due to abnormal distribution of force - growth plate manipulation/osteotomy

Question 38

what technique can be used for leg length discrepancies

Answer 38

shorten/lengthen limb appropriately

Question 39

what is the main indication for arthroplasty/joint replacment in an arthritic joint

Answer 39

pain