Surgical Procedures Flashcards
8 Indications for Surgery for Musculoskeletal Disorders
- Incapacitating pain at rest or with functional activities
- Marked limitation of active or passive motion
- Gross instability of a joint or bony segment
- Joint deformity or abnormal joint alignment
- Significant structural degeneration
- Chronic joint swelling
- Failed conservative or previous surgical management
- Significant loss of function leading to disability as the result of any of the preceding factors
Preoperative education improves what 4 things postoperatively?
- increased the health related quality of life
- decreased the # of hours of therapy needed during inpatient stay
- decreased patient anxiety during recovery/acute care stay
- decreased pain levels and decreased requests for pain medication
The inflammatory phase for bone is from day _ to day _
1 - 7 days
When is the soft callus forming during bone healing?
weeks 2 - 3
When is the hard callus forming during bone healing?
3 - 4 months
How long does the entire remodeling of bone process take?
Up to one year
When does near normal tensile strength (NNTS) in muscle return?
7 days
Ligaments and tendons take _ months for an 85-95% return of NNTS.
4
The inflammatory phase for ligament/tendon is from day _ to day _
1 to days 3 or 5
When is the proliferative (repair) phase of ligament/tendons?
Day 3-Day 21
When does the remodeling phase for ligaments begin?
day 21
When does the remodeling phase for tendons begin?
day 42
Why is muscle setting important during the repair and remodeling phases of healing?
It is important to avoid adhesions
Why does articular cartilage have limited healing potential?
Due to its lack of a clotting cascade
What are the 3 phases of healing?
1) Acute/Inflammatory
2) Subacute/Proliferative
3) Chronic Remodeling
What is the time frame for the maximum protection phase of tissue healing?
From a few days to 6 weeks (tissue dependent)
What is the time frame for the moderate protection phase of tissue healing?
Usually begins 4-6 weeks post-op
What is the time frame for the minimum protection phase of tissue healing?
6-12 weeks post-op; may continue to 6 months post-op and beyond
How long does skin healing take?
7 - 14 days
When do staples/sutures come out?
Day 14
When should staples/sutures come out of a revised, total, or infected knee?
Day 21 secondary to compromised wound
Which heals better, staples or sutures?
sutures
When is bone at its weakest?
During weeks 3 and 4
Healing time ____ in smokers
doubles
3 types of pulmonary complications post-op
- Pneumonia
- Atelectasis
- Pulmonary embolism
Elevated HR is indicative of what type of pulmonary complication
a pulmonary embolism
What is DVT?
Deep Vein Thrombosis
which is the formation of a blood clot (thrombus) in a deep vein
What are the risk factors for DVT?
- postop or post fracture immobilization
- prolonged bed rest
- sedentary lifestyle
- trauma to venous vessels
- limb paralysis
- malignancy
- advanced age
- obesity
- congestive heart failure
- use of oral contraceptives
- pregnancy
How can 20-25% of DVTs and PEs be identified?
by dull aching, severe pain, swelling, heat and redness of skin
What is the only way to confirm the presence of a DVT?
Diagnostic imaging
4 Ways to avoid venous stasis (DVTs)
- Initiating ambulation after surgery ASAP
- Foot AROM
- Compression stockings
- SCDs
What is a pulmonary embolism?
When a clot breaks away from the wall of a vein and travels proximally to the lungs
5 Signs/Symptoms of Pulmonary Embolism
- Sudden onset of SOB (Dyspnea)
- Rapid, shallow breathing (Tachypnea)
- Chest Pain
- Fever, sweating, cough, hemoptysis
- Elevated heart rate (Tachycardia)
How long should DVT and PE patients be on blood thinners after hospital D/C?
6 months
Example of a repair surgery
ACL
Example of a release or decompression surgery
arthroscopic subacromial decompression
Example of a realignment or stabilization surgery
Osteotomy
Example of a reconstruction or replacement surgery
arthroplasty
Example of a fusion or fixation for bony union surgery
ORIF such as Lumbar spine fusion
3 types of tissue grafts
- Autograft
- Allograft
- Synthetic graft
Describe an autograft and give an example
This type of graft uses the patient’s own tissue harvested from a donor site in the body.
Example: Patellar tendon grafts are used for ACL/PCL repair surgery.
Describe an allograft and when it is used
Usually cadaveric. Used if autograft is unavailable or has failed.
Vigorous stretching and full level activity are contraindicated for _ - _ weeks postoperatively a repair, reattachment, reconstruction, stabilization, or transfer of soft tissues
6-8 weeks
Why do tendon repairs have a longer immobilization period than muscle?
Because they have decreased blood supply therefore healing is slower
Why is remobilization with limited tensile force initiated as early as possible after tendon repair?
to prevent adhesions because tendons need to glide within their sheath
After tendon repair restricted weight bearing and lifting occurs for _ - _ weeks
6-8 weeks
After tendon repair vigorous stretching and high intensity resistance exercise should not be initiated until _ weeks
8
Ligament Repair vs. Reconstruction
Repair involves approximating and suturing
Reconstruction involves the use of a tissue graft
How long does it take for full rehab after a ligament repair or reconstruction?
6 months to 1 year
Which joint is the most commonly stabilized and reconstructed joint?
The GH joint
How does transfer or realignment of a muscle-tendon unit affect the unit?
It alters the line of pull of a muscle, but it does not change the action
Example: realignment of the quadriceps changes the line of pull, but not the mechanism
How does transfer or realignment of a tendon from one bony surface to another affect the unit?
It alters the line of pull of a muscle as well as the action of the muscle
Example: moving the flexor carpi ulnaris to the dorsal surface of the hand changes the action from a flexor to an extensor.
What are the indications for release, lengthening, or decompression of soft tissue (myotomy, tenotomy, or fasciotomy)?
Contracture prevention or minimizing progressive deformity; such as in muscular dystrophy and cerebral palsy.
Postop soft tissue release or lengthening what position should the affected limb be immobilized?
in a LENGTHENED position, except during exercise
What is a synovectomy?
Removal of synovium (joint lining) in the presence of chronic joint inflammation
When is a synovectomy indicated?
When medical management has failed for 4-6 months
What type of patients typically undergo synocevtomies?
Patients with Rheumatoid Arthritis
Following a synovectomy what should you avoid?
excessive exercise or activity that increases joint pain or swelling
What is an example of an arthroscopic debridement or repair surgery?
Meniscal tears
Are articular cartilage procedures and postop management easy?
NO, they are typically slow and grueling
Protected weight bearing should continue until week _ or _ after articular cartilage procedures
8 or 9
What are the disadvantages of excision arthoplasty?
- Joint instability
- In the hip, leg length discrepancy
- Muscular imbalance and weakness
What is excision arthroplasty and in what body part is it typically performed in?
A flexible silicone implant is placed where the articular surface was removed where is becomes encapsulated with fibrous tissue as the jont reforms
Performed primarily in the fingers
What is interposition arthroplasty and in what body part is it typically performed in?
It is the biological resurfacing of a joint to provide a new articular surface
Performed in elbows usually after failure of total elbow replacement or in extremely young patient
What is the absolute contraindication to total joint arthroplasty?
Active infection in the joint
What is Arthrodesis?
Surgical fusion of the surfaces of a joint
What is the optimal position for hip arthrodesis?
10-15 degrees of flexion
What is the optimal position for ankle arthrodesis?
90 degrees
Restricted weight bearing until _ - _ weeks post-arthrodesis
8-12
What is an osteotomy?
A surgical operation whereby a bone is cut to shorten, lengthen, or change its alignment
How long does a bony union take after an osteotomy?
8-12 weeks
Increased tourniquet time increases the risk of what?
DVTs and nerve impairment
After a total hip surgery the hip is put into what 3 positions to determine intraoperative stability?
- Extreme hip flexion
- Extension and external rotation
- Flexion and internal rotation
