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Shay Hartman's > Medical Conditions (Complete) > Flashcards

Medical Conditions (Complete) Flashcards

1
Q

Rheumatoid Arthritis

What are the preoperative considerations for a patient with RA?

[JAAOS 2015;23:e38-e48]

A
  1. Timing of surgery
  • Consider earlier surgery due to:
    • Less joint destruction
      • More options, less difficult
    • Less complications
  1. Sequence of surgery
  • Lower extremity procedures before upper extremity
    • Preserves ambulatory capacity
    • Reduces risk of damaging upper extremity procedures during lower extremity rehab
  • Sequence of lower extremity procedures
    • Forefoot, hip, knee, hindfoot, ankle
      • Forefoot
        • Symptomatic relief
        • Lowers risk of ulcer and infection
      • THA before TKA
        • Restore femoral length
        • Adequate hip ROM aids rehab of TKA
  • Sequence of upper extremity procedures
    • Hand, wrist, elbow, shoulder
      1. Medical considerations
  • Comorbidities
    • Optimize CV and resp
  • Perioperative medication management
    • Methotrexate - continue
    • Hydroxychloroquine - continue
    • Azathioprine - discontinue 1 week preop
    • NSAIDs - discontinue 1 week preop
    • ASA - discontinue at least 72 hours preop
    • TNF-α inhibitors: (D/C 2 half-lives preop)
      • Etanercept - discontinue 1 week preop
      • Adalimumab - discontinue 4 weeks preop
      • Infliximab - discontinue 4 weeks preop
      • ***NOTE: When to restart:
        • 1-2 weeks post if wound healing and no infection
        • Immediately if flare
        • Delayed if infection
          • Start 1 week after last sign of infection
    • Steroids [Arthritis Care Res (Hoboken). 2017;69(8):1111-1124]
      • Continue current daily dose rather than stress dosing
        • If ≤16 mg/day prednisone or equivalent
          4. Anaesthesia considerations
  • Spine instability
    • Flex-ex views
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2
Q

Rheumatoid Arthritis

What are extra-articular features of RA?

[JAAOS 2015;23:e38-e48]

A
  1. CVD
  2. Interstitial lung disease
  3. Rheumatoid nodules
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3
Q

Rheumatoid Arthritis

What are the orthopedic manifestations of RA?

[Orthobullets]

A
  1. Spine
  • Basilar invagination
  • Atlantoaxial instability
  • Subaxial instability
    2. Hand
  • Ulnar drift at MCP
  • Boutonniere deformity
  • Swan neck deformity
  • Trigger finger
  • Mannerfelt syndrome (FPL rupture)
  • FDP/FDS rupture
  • Extensor tendon rupture
    • Occurs ulnar to radial (EDM – EDC – EPL)
      1. Elbow
  • Rheumatoid elbow
    4. Shoulder
  • Central glenoid wear
  • Periarticular osteopenia
  • Cysts
  1. Hip
    * Protrusio acetabuli
  2. Foot
  • Hallux valgus
  • Claw toe
  • MTP subluxation
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4
Q

Rheumatoid Arthritis

Summary of operative considerations for a patient with RA

A
  1. Consider earlier surgery and sequence of surgery (if muli-joint involvement)
  2. Preoperative considerations
  • C-spine flex-ex views
  • Anaesthesia consultation
    • Spine instability:
      • Opt for regional anaesthesia or fiberoptic intubtation
    • Cricoarytenoid arthritis (avoid LMA)
    • CVD and resp disease
  • Medicine consultation
    • CV assessment (CVD, valvular disease)
    • Respiratory assessment (ILD)
  • Rheumatology consultation
    • Medication management
      • Continue, hold, stress dose steroids, restart
        3. Intraoperative
  • Positioning
    • Aware of other joint involvement
    • Protect soft tissues
    • Osteoporosis
  • Preop Abx dose
  • Gentle handling of soft tissues
    4. Postoperative
  • Postop Abx doses
  • DVT prophylaxis
  • Restart medications
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5
Q

Anklyosing Spondylitis

What are the orthopedic manifestations of AS?

[JAAOS 2005;13:267-278]

A
  1. Sacroilitis
    * SI joints usually first joint involved
  2. Enthesopathy leading to fusion of the facet joints and disc space
    * Occurs caudal to cranial
  3. Spinal osteopenia
  4. Loss of sagittal balance
  • Due to progressive cervical and thoracic kyphosis and loss of lumbar lordosis
  • Normally plumb line from centre of C7 touches anterior edge of S1
  1. Hip and knee flexion contractures
  2. Ankylosis of peripheral joints (hip, knee, shoulder)
  3. Extra-spinal enthesopathy (eg. achilles)
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6
Q

Ankylosing Spondylitis

What are nonorthopedic manifestations of AS?

[JAAOS 2005;13:267-278]

A
  1. Acute anterior uveitis
  2. Psoriasis
  3. IBS
  4. Pulmonary fibrosis
  5. Aortitis
  6. Aortic and mitral regurgitation
  7. RBBB
  8. AV block
  9. GU problems
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7
Q

Ankylosing Spondylitis

What are physical examination special tests for AS?

[JAAOS 2005;13:267-278]

A
  1. Chest expansion <2.5cm measured at 4th intercostal space
    * Indicates costovertebral fusion
  2. Schober test
  • <5cm increase in distance from points measured 5cm below and 10cm above PSIS measured in standing and forward flexion
    • Indicates reduced thoracolumbar motion
  1. Occiput-to-wall distance
    * Normal 0-2cm
  2. Chin-brow angle
  3. Gaze angle
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8
Q

Ankylosing Spondylitis

What are spinal complications in AS?

[JAAOS 2005;13:267-278]

A
  1. Fracture
  2. Pseudoarthrosis
  3. Spondylodiscitis
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9
Q

Ankylosing Spondylitis

What is the diagnostic criteria for AS?

[JAAOS 2016;24:241-249]

A

Modified New York criteria for AS

  • Clinical criteria
    • Low back pain and stiffness for >3 months, which improves with exercise but is not relieved with rest
    • Limitation of motion of the lumbar spine in both sagittal and frontal planes
    • Limitation of chest expansion relative to normal values corrected for age and sex
  • Radiological criteria
    • Bilateral sacroiliitis grade ≥2
    • Unilateral sacroiliitis grade 3-4

***Definite AS = the radiological criterion is associated with at least one clinical criterion

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10
Q

Ankylosing Spondylitis

Summary of operative considerations for a patient with AS

A
  1. Preoperative considerations
  • Anaesthesia consultation
    • Airway
      • Chin-to-chest, Kyphosis, TMJ involvement

Awake fiberoptic intubation

* Ventilation
    * Decreased chest expansion * Medicine consultation
* CV and respiratory
  • Rheumatology consultation
    • Medication management
  • Ophthalmology consultation
    • Uveitis
  • Spine fracture
    • Positioning
    • CT/MRI (full spine)
    • Long constructs
  1. Intraoperative consideration
  • Positioning
    • Careful transfers
    • Deformity
    • Osteoporosis
    • Contractures
    • Other joint involvement
  • Preop Abx dose
  • Blood loss
  • THA
    • Contractures
    • Increased anteversion
    • Ankylosis
    • Protrusio
  • Spine
    • Neuromonitoring
    • Osteoporosis
    • Deformity
    • Long constucts
      1. Postoperative considerations
  • HO prophylaxis in high risk patients
    • Eg. ankylosis, previous surgery
  • Postop Abx
  • DVT prophylaxis
  • Restart medications
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11
Q

Paget’s Disease

Preoperative considerations

A
  1. Anaesthesia consult
  2. Medicine consultation
    * High output cardiac failure – Echo
  3. Rheumatology
  • Bisphosphantes if active disease – monitor ALP
    • Proceed once at low level
  1. Full length xrays
    * Assess for deformity
  2. Consider autologous blood donation
  3. Implant selection based on deformity
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12
Q

Paget’s Disease

Intraoperataive considerations

A
  1. Blood loss
  2. Preop ABx
  3. THA
  • Femoral deformity
  • Narrow canals
  • Hard bone
  • Sharp reamers
  • Acetabular protrusio
  • Liberal soft tissue release
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13
Q

Paget’s Disease

Postoperative considerations

A
  1. HO prophylaxis
  2. Post op Abx
  3. DVT prophylaxis
  4. Continue bisphosphonate if active disease
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14
Q

Down Syndrome

What is the genetic cause?

[JAAOS 2006;14:610-619]

A

Trisomy 21

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15
Q

Down Syndrome

What are the phenotypic features of Down Syndrome?

[JAAOS 2006;14:610-619]

A
  1. Facial features
  • Flat nasal bridge
  • Epicanthal folds
  • Upward-slanting palpebral fissures
  • Open mouth
  1. Hand abnormalities
    * Small finger hypoplasia
    * Small finger clinodactyly
    * Single, deep palmar crease (simian crease)
  2. Characteristic pelvis with lateral flare of iliac wings
  3. Joint hypermobility
  4. Ligamentous laxity
  5. Hypotonia
  6. Short stature
  7. Mental impairment
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16
Q

Down Syndrome

What are the associated medical conditions with Down Syndrome?

[JAAOS 2006;14:610-619]

A
  1. Cardiac
  • Congenital heart disease
  • ASD/VSD
  • Patent ductus arteriosus
  • Tetralogy of Fallot
  1. Leukemia
  2. Ear
  • Hearing loss
  • Otitis media
  1. OSA
  2. Eyes
  • Refractive errors
  • Strabismus
  • Congenital cataracts
    6. GI
  • Duodenal atresia
  • Hirschprungs
  • Celiac disease
    7. Psychiatric
  • Mental impairment
  • Early onset Alzheimer’s
    8. Endocrine disorders
  • Hypothyroidism
17
Q

Down Syndrome

What are the MSK conditions associated with Down Syndrome?

[JAAOS 2006;14:610-619]

A
  1. Joint hypermobility/ligamentous laxity
  2. Arthropathy of Down Syndrome (similar to JIA)
  3. Upper cervical instability
  • Atlantoaxial instability
  • Atlanto-occipital instability
  1. Scoliosis
  2. Hip instability
  3. SCFE
  4. Patellar instability
  5. Foot disorders
  • Pes planus
  • Hallux valgus
  • Metatarsus primus varus
18
Q

Down Syndrome

List abnormalities of the cervical spine in Down’s syndrome

[JAAOS 2006;14:610-619]

A
  1. Atlantoaxial instability
  2. Atlantooccipital instability
  3. Os odontoideum
  4. Persistent dentocentral synchondrosis of C2
  5. Spina bifida occulta of C1
  6. Ossiculum terminale

Shay Hartman's (29 decks)

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