Principles of orthopaedic surgery

Question 1

What general checks should be done pre-operation?

Answer 1

• Observations: blood pressure, pulse, temp.
• History (PMH and DH in particular): patient may be on warfarin and will need to stop taking it prior to the surgery
• Systemic enquiry: are they fit for surgery?
• Examination: cardiorespiratory examination
• Blood tests: FBC, glucose, urea, U&Es, LFTs, clotting screen
• Blood group: in case of blood loss
• Urinalysis: for UTI, should be treated prior to any orthopaedic operation

Question 2

What checks should be done to the limb before orthopaedic surgery?

Answer 2

• note skin condition (rash?)
• pulses of the limb
• range of movement
• look for any distal infection
• Eg. a knee replacement procedure should not be carried out in a patient with an infected ingrowing toenail

Question 3

Give 2 examples of procedures that are done by arthroscopy.

Answer 3

• stabilisation of rotator cuff repair in the shoulder
• meniscal repair or ACL reconstruction in the knee

Question 4

Joint arthrodesis diagrams…

Answer 4

• A: internal fixation (screw)
• B: intramedullary nail

Question 5

What is the advantage of joint arthroplasty over joint arthrodesis?

Answer 5

• movement is maintained in joint arthoplasty and therefore function
• mobility will never be normal but pain will not be there anymore

Question 6

Knee replacement x-ray…

Answer 6

Question 7

Hip replacement x-ray…

Answer 7

Question 8

What are the most common reasons for failure of an implant?

Answer 8

• loosening
• infection
• fracture
• (implants usually last 15 years, less in more active patients)

Question 9

When is osteotomy used?

Answer 9

To correct deformities…
- Hallux valgus
- Arthritic knees in younger patients to offload arthritic components (reduces pain and postpones need for arthroplasty)

Question 10

What is a synovectomy?

Answer 10

• removal of synovial lining of the diseased joint or the tenosynovium around tendons

Question 11

What are the 3 possible beneficial effects of a synovectomy?

Answer 11

• reduction of swelling
• slowing of disease progression
• prevention of tendon rupture
• (note: not possible to remove whole synovium and symptoms often return, usually performed at the wrist)

Question 12

What general post-operative care should be done?

Answer 12

• Regular obvs recordings
• adequate analgesia
• Bloods: FBC, U&E
• X-ray of operated joint
• Early mobilisation encouraged: MDT needed
• distal neurovascular examination should be done

Question 13

Local complications of orthopaedic surgery (immediate)…

Answer 13

Question 14

Local complications of orthopaedic surgery (early - up to first 4 weeks)…

Answer 14

Question 15

Local complications of orthopaedic surgery (late - can occur at any time)…

Answer 15

Question 16

What perioperative factors can be done to reduce the risk of infection?

Answer 16

• laminar airflow theatre (air is filtered)
• adequate skin preparation and exclusion drapes
• sterile instruments and prostheses
• careful surgical technique (including haemostasis - stopping bleeding)
• use of antibiotic-loaded cement in joint arthroplasty

Question 17

What is the management for hypovolaemic shock post-operation?

Answer 17

• oxygen therapy
• fluid replacement

Question 18

Name two processes that are carried out to prevent wrong-side surgery from occurring and explain why they are effective

Answer 18

• Never-event list: for organisations to raise awareness to prevent event
• Consent process: patient agreeing to the procedure, including the site
• Side marking: patient agreeing to the site/side and marking with a pen, correlate the consent form and the clinical information