Week 5 - A - Elective Surgery (1) - Surgical strategies for managment of an arthritic joint

Question 1

Elective (scheduled) orthopaedic surgery involves the treatment of non‐emergency or “cold” musculoskeletal conditions. There are different surgical strategies for management of an arthritic joint

What is the treatment that literally means reshaping of the joint?

Answer 1

This would be arthroplasty

Question 2

Arthroplasty is also synonymous with joint replacememnt in most circumstances

What is it known as when arthroplasty is used to remove a section of diseased joint?

Answer 2

Excision or resection arthroplasty

Question 3

Joint replacement involves either removing the whole joint or part of the joint

What are both known as?

Answer 3

Total joint replacement or hemi-arthroplasty

Question 4

What are the most well established and successful joint replacements?

Answer 4

This would be knee and joint hip replacement

Question 5

What are the 4 components of the total hip replacement joint? Remember 2parts make up the acetabulum (socket) and two make up the femoral head (ball)

Answer 5

Acetabulum parts - shell and liner

Femoral head parts - head and stem

Question 6

+Joint replacements can be made of stainless steel, cobalt chrome, titanium alloy, polyethylene and ceramic. Components may or may not be cemented with advantages and disadvantages of both.

Why will the joint replacement ultimately fail?

Answer 6

The joint replacement will ultimately fail because of the loosening of the joint (caused by wear particles producing an inflammatory response or due to high stresses) or breakage of the joint replacement components

Question 7

Metal particles can cause an inflammatory granuloma which can cause muscle and bone necrosis What is this known as?

Answer 7

This inflammatory granuloma is known as a pseudotumour - can cause muscle and bone necrosis

Question 8

polyethylene particles can cause an inflammatory response in bone What can this do to the bone? What can happen in the ceramics due to the fatigue caused by this?

Answer 8

This can result in subsequent osteolysis (bone resorpiton) resulting in loosening and

ceramics can shatter due to fatigue

Question 9

Once a joint replacement fails a revision (redo) procedure to remove the old components and insert a new replacement is much more difficult than the first procedure, What age group of patients are more likely to be considered for a first total joint replacememnt?

Answer 9

This is why joint replacements are considered more in the elderly population - because joint replacements loosen after some years (around 15/20 years) and carrying out a second replacement is risky

Question 10

Serious complications of joint replacement can occur including deep infection, recurrent dislocation, neurovascular injury, pulmonary embolism and medical complications (renal failure, MI, chest infections etc).

Which of these complications are late or early?

Answer 10

• Prosthesis loosening - late
• Thromboembolic disease - late
• Vascular injury - intra-operative injury
• Dislocation - this is usually an early complication
• INfection - early complication

Question 11

Deep infection can cause a serious problem which is why in orthopaedics in particular, strict aseptic and antiseptic precautions are taken in theatre

if infection is diagnosed within the first couple of weeks (fulminant infection), what is carried out?

Answer 11

Carry out a surgical washout and debridement of the joint and prolonged parenteral antibotics (around 6 weeks) can be attempted to salvage the artifical joints (around 50% successful)

Question 12

Name some other early complications of joint replacement?

Answer 12

Infection,

vascular injury,

nerve injury,

DVT formation and

dislocation

Question 13

Name some other late complications?

Answer 13

Loosening,

fracture,

pseudotumour formation

Question 14

Reasses What causes pseduotumour formation?

Answer 14

Metal particles causing an inflammatory granuloma which can cause bone and muscle necorosis

Question 15

What percentage of patients die as a result of knee or hip replacement?

Answer 15

0.2%

Question 16

This procedure involves the removal of bone and cartilage of one or both sides of a join from a diseased joint What is this again?

Answer 16

Excision or resection arthroplasty

Question 17

Excision/resection arthroplasty can be an effective procedure for smaller joints What is the excision arthroplasty known as Keller’s procedure used in?

Answer 17

This is used in hallux valgus (a bunion) - removing some of the disease bone

Question 18

Would surgery eg excision arthroplasty be given for cosmetic reasons alone in a patient with hallux valgus?

Answer 18

No - surgery should not be given for cosmetic reasons alone

Question 19

What is the means of stiffening or fusion of a joint in a position of function. This is gold standard treatment for hallux rigidus? What is hallux rigidus?

Answer 19

This would be arthrodesis - the remaining hyaline cartilage of the joint and subchondral bone is removed and the joint is stabilized resulting in bony union (like fracture healing) and fusion.

Hallux rigidus is OA of the big toe

Question 20

surgical realignment of a bone which can be used for deformity correction or to redistribute load across an arthritic joint. What is this procedure?

Answer 20

Osteotomy - Osteotomy can be used for early arthritis in the knee and hip.

Question 21

What is the aim of osteotomy in arthritis?

Answer 21

The aim is to offload the pressure from the diseased part of the joint and shift it to an undiseased part

Question 22

So what are the four elective surgical managements of an arthritic joint?

Answer 22

Arthroplasty - joint replacement

Excision/resection arthroplasty - removal of the diseased bone / cartilage eg in hallux valgus

Arthrodesis - fusion of the joint ie in hallux rigidus

Osteotomy - for limb realignment or to offload pressure from a diseased part to undiseased part of the joint

Question 23

Apart from in hallux rigidus, when else is arthrodesis used?

Answer 23

Arthrodesis is good for end stage ankle arthritis and wrist arthritis

Question 24

What does arthrodesis prevent women wearing in hallux rigidus treatment?

Answer 24

Prevents women wearing high heels

Question 25

If conservative treatment for hallux valgus does not work, what is a surgical treatment option?

Answer 25

Excision/resection arthroplasty - also known as Keller’s procedure

Question 26

What is the treatment that can be given to lengthen or reshape limb bones? Give an example of a condition that it is used in?

Answer 26

Ilizarov technique - limb lengthening with a circular frame external fixator

Used in fibular hemimelia - congenital limb deformity where part or all of the fibular bone is missing