Orthopaedics unit 1 joint conditions - deck 2

Question 1

What is all management options of OA aimed at providing ?

Answer 1

Pain relief and through this return of function of the joint

Question 2

What are the 3 main non-surgical (conservative) options in the treatment of OA ?

Answer 2

1. weight loss
2. use of a stick
3. rest and physiotherapy.

Question 3

Why is weight loss so useful in the treatment of OA ?

Answer 3

This is because lower limb joints in particular are subject to large loads, as a result of the leverage exerted by the muscles around the joints. The resulting joint loads may be several times the body weight they are supporting

e.g. in the hip during the stance phase of walking the joint loading can reach about x3 of body weight

Therefore small reductions in body weight can result in significant reductions in total loads on a joint and ==> help treat the patients pain

Question 4

What group of muscles is efficient walking highly dependent on and why ?

Answer 4

Efficient walking is highly dependent on the ability of the abductor muscles this is because when we walk the abductor muscles contract on the weight bearing side i.e. when the weight is through the right leg (this one is planted on the ground) and trying to move the left, the abductor muscles contract on the right side to tilt the left side of the pelvis upward, permitting the left leg to swing forward freely to make contact with the ground

Question 5

Why is a stick useful in helping treat lower limb disease especially in the hip e.g. OA of the hip ?

Answer 5

The use of a stick in the opposite hand means the shoulder girdle can help in tilting the pelvis and ==> has the effect of reducing the work required of the weight bearing abductor muscles thereby dramatically reducing the muscle induced loads on the hip.

Question 6

Why must there be a balance between physiotherapy and rest in the treatment of OA ?

Answer 6

The muscles work most efficiently when they are in regular use, but over-exercise cannot in the long term be beneficial but some exercise does relieve stiffness and muscle spasm and therefore pain whereas excessive resting of muscles around a painful joint will make them go into a spasm

Question 7

What are the 4 main surgical options for most forms of arthritis ?

Answer 7

1. Nothing
2. Arthrodesis
3. Osteotomy
4. Arthroplasty.

Question 8

What must always be considered when deciding whether or not to perform a surgery ?

Answer 8

The benefits of surgery must outweigh the risks.

Question 9

Who has the biggest say in whether or not a patient will undergo a surgery ?

Answer 9

Provided the patient has a good grasp of the risk (benefit ratio in their particular case) then they may have the biggest say in the decision of whether to have or not have surgery.

Question 10

Define what arthrodesis is

Answer 10

This is the surgical imobilisation of a joint by fusion of the bones in a position of function

Essentially, a relatively stiff and very painful joint is cut out and the remaining raw bone ends are held together either by an external splint or screws until they heal with a bony bridge e.g. in the hip fusion in 30 degrees of flexion and some adduction produces pain free functional gait, whilst permitting sitting.

Question 11

Who is arthrodesis most suited for ?

Answer 11

A young person with a painful and limited range of movement in the affected joint.

Question 12

Why is the more attractive surgical option of joint replacement rather than arthrodesis for a young person with a painful and limited range of movement in the affected joint not a safe choice ?

Answer 12

add in explanation

Question 13

Why is arthrodiesis not an easy procedure to do in large joints such as the hip ?

Answer 13

Because once the joint is removed the bones are difficult to hold together

Question 14

How long is the recovery from arthrodesis usually ?

Answer 14

Up to 6 months, often in a plaster splint

Question 15

What is the main long-term disadvantage of arthrodesis ?

Answer 15

It puts stress on the adjacent joints. e.g. fusion of the hip, means extra stress on the lumbar spine and knee as well as the opposite hip

Question 16

How can the disadvantage of arthrodesis putting extra stress on adjacent joints be counteracted ?

Answer 16

By electing to fuse the joint until the fifth decade and then performing a second operation to “unpick” the arthrodesis and convert it to an arthroplasty.

This double operation has proved to be surprisingly effective for the hip, giving good return to function.

Question 17

What are the two main joints which can be useful fussed (arthrodesis performed)? and why is joint replacement not useful for them ?

Answer 17

The ankle and wrist - at present they difficult to replace and have a limited range of functional movement whether an arthrodesis or arthroplasty is perfomed

Question 18

Why do patients sometimes have difficulty choosing the option of arthrodesis ?

Answer 18

This is because patients generally have unrealistic ideas of the effectiveness of arthroplasty

Question 19

Define what an osteotomy is and describe the aim of performing this procedure

Answer 19

This is surgical realignment of a joint

The aim is to redirect forces across a joint so that they more evenly distribute the load to which the joint is subjected.

Question 20

Generally speaking when/why may an osteotomy be perfomed ?

Answer 20

When a joint has become deformed and the loads crossing it are distorted by the deformity e.g. in the knee, if the person becomes bow-legged, all the load passes down the medial side of the joint rather than down the middle

Pic shoes line of where the loading forces are mainly passing through in varus and valgus deformed legs

Question 21

Describe the difference between varus and valgus deformities

Answer 21

The terms valgus and varus refer to angulation (or bowing) within the shaft of a bone or at a joint.

It is determined by the distal part being more medial or lateral than it should be. Whenever the distal part is more lateral, it is called valgus. Whenever the distal part is more medial it is called varus

Question 22

What is the reason for varying popularity of osteotomies in different parts of the world ?

Answer 22

Possibly due to the fact accurate surgical realignment is technically highly demanding and very time consuming resulting in widely differing results are achieved

Question 23

An osteotomy is viewed only as a temporary measure - how long are they typically effective for ?

Answer 23

1/2 years to 10 years

Question 24

Who may an osteotomy be useful in the treatment of arthritis?

Answer 24

The young who have maintained a good range of movement, despite the pain, and have a reasonable preservation of articular cartilage. Which is typical of the early stages of OA.

Note that If the range of movement is severely limited then a simple realignment is unlikely to succeed because useful function cannot be restored.

Question 25

Name two main joints which are suitable for osteotomy ?

Answer 25

The hip and knee

Question 26

Define what an athroplasty is

Answer 26

This is a surgery which creates a new joint or changes the shape of a joint.

Question 27

What does the name ‘‘arthroplasty’’ literally mean ?

Answer 27

It means ‘‘to reshape a joint’’

but now arthroplasty is taken to mean the replacement of one or both surfaces of a joint.

Question 28

What are the limitations in using a joint replacement to treat someone ?

Answer 28

It can relieve pain and the restriction of movement which pain brings

but is not likely to alleviate disability due to stiffness caused directly by the disease within the joint.

Question 29

What are the success rates of arthroplasty in general ?

Answer 29

Well in excess of 90% will still be in place after 10 years

Question 30

What is the important difference to remember between an artificial joint (i.e. when someone has had a joint replacement) and a natural joint ?

Answer 30

Its important to remember that an artificial joint from the moment it is put in, begins to wear out, whereas a natural joint has the capacity to regenerate.

Question 31

What is the most common disabiliing form of disease in the UK?

Answer 31

OA of the knee

Question 32

How is the relationship between pain and function different when considering arthroplasty of the upper limb compared to the lower limb ?

Answer 32

The loads involved in the upper limb e.g. shoulder and elbow are relatively low, but the range of motion required for normal function of joints of the upper limb is large.

This is why it is important to remember that arthroplasty tends to improve pain related loss of function but does relatively less for intrinsic stiffness (range of motion) ==> joint replacements in the upper limb are not as successful as in the lower limb

Question 33

Why is arthroplasty good at reducing pain usually but not at reducing stiffness (increasing range of motion) ?

Answer 33

This is because soft tissue distortion of the capsule and ligaments tends to remain after replacing the articular surfaces

Question 34

Give some examples of why it is important to retain range of motion in the upper limb

Answer 34

The elbow must flex to ninety degrees to permit eating (try reaching your mouth with an arm fixed at a greater angle) and must extend more or less fully to reach the anus for cleansing.

Question 35

Which arthroplasty in the upper limb are slowly reaching the high functional requirements of the upper limb and ==> becoming acceptable and which are not

Answer 35

Elbow and shoulder joint replacements approaching these high functional requirements but not so for the fingers or the wrist.

Question 36

What are the main requirements for a ‘successful’ artificial joint

Answer 36

Capable of a functional and pain free range of motion

Be able to withstand the significant forces placed upon it without undue wear and without working loose

Have the same stability as the natural joint

Question 37

What was the first really successful joint replacement out of all the joints ?

Answer 37

The hip

Question 38

Why is the hip joint replacement so successful ?

Answer 38

The stable configuration of a ball and socket joint

And the fact that the functional range of hip motion is in practice fairly limited. In practical terms if we even only retain 10-15 degrees of extension and 30-50 degrees of flexion with a few degrees of abduction and rotation then useful hip function in daily living is maintained.

Question 39

The functional range of movement of the knee is relatively small but what degree of flexion must be achieved in order to get up and down the stairs

Answer 39

90 degrees

Question 40

In the knee, stability in extension is essential so that we can support the full weight of the body whilst standing on a single straight leg - how is this achieved by the surgeon performing a joint replacement ?

Answer 40

The surgery must achieve an accurate soft tissue balance through dissection of the capsule and the ligaments.

The surgeon must balance the collateral ligaments by cutting tight parts of the ligaments and then putting in artificial surface replacements of sufficient thickness to retighten the ligaments so that the medial and lateral collateral ligaments are under equal tension.