Week 7 content - surgeries

Question 1

two types of approaches in THR

Answer 1

o Posterior:
 Most commonly used.
 Advantage – good vision for surgeon.
 Disadvantage – possibility of dislocation and gluteal muscle sciatic nerve.
 Dislocating position – flex >90 degrees, adduction past neutral, internal rotation past neutral & combined flexion, adduction and internal rotation.

o Anterior:
 Becoming more common.
 Advantage – decreased chance of dislocation, muscle sparing, may be faster recovery.
 Disadvantage – more difficult for surgeon as there are more blood vessels and nerves anteriorly.
 Dislocation position – forced extension & flexion or extension with adduction and external rotation.

Question 2

perioperative complications for THR

Answer 2

 Sciatic nerve (posterior approach) and femoral nerve (anterior approach) can lead to short term neuropraxia and subsequent foot drop or quads weakness.
 Poor positioning of components: femoral stem valgus/varus alignment, leg length discrepancy and acetabular component malposition could increase the chance of dislocation.
 Fractured acetabulum; fractured femoral shaft; excessive blood loss.

Question 3

post operative complications

Answer 3

o Post operative complications:
 Cardiac
 DVT or PE.
 Dislocation
 Infection
 Loosening of components.

Question 4

post-op physio management of THR

Answer 4

o Goals:
 Independent mobility with appropriate aid.
 Independent with home exercise programme.
 Independent mobility on stairs.

Question 5

arthroscopy

Answer 5

→ Performed through small portals to allow an irrigation cannula, a fibre optic viewer and light source, and surgical instruments into the joint.

→ Uses of arthroscopic surgery:
o To establish or define accuracy of diagnosis.
o Help decision making and planning of surgery.
o Observe and record progression on knee joint disorder.
o Perform operative procedures.

→ Advantages of arthroscopic surgery:
o Rapid recovery
o No hospitalisation and no or limited need for walking aids.

Question 6

types of meniscal arthroscopy surgeries

Answer 6

→ Performed through small portals to allow an irrigation cannula, a fibre optic viewer and light source, and surgical instruments into the joint.

→ Uses of arthroscopic surgery:
o To establish or define accuracy of diagnosis.
o Help decision making and planning of surgery.
o Observe and record progression on knee joint disorder.
o Perform operative procedures.

→ Advantages of arthroscopic surgery:
o Rapid recovery
o No hospitalisation and no or limited need for walking aids.

Question 7

Arthroscopic knee surgery

Answer 7

→ Mosaicplasty – the transfer/replacement of cartilage in either 1 piece of several small pieces for a cartilage defect (OCD). Lacks good clinical studies.

→ Autologous chondrocyte implantation (ACI) – healthy cartilage is taken, s. ent to labs for processing. Periosteal flap from tibia is inserted into knee. Cartilage is sent back to surgeon and cultured cartilage cells injected under periosteal flap.

→ Matrix induced chondrocyte implantation (MACI) – similar to ACI but cartilage cultured on a membrane and inserted into knee. No periosteal flap. Membrane with cartilage creates a matrix that covers the articular surface.

Question 8

3 way patella realignment

Answer 8

→ Tibial tuberosity transfer - Surgically moving the tibial tuberosity medially.
→ Lateral release- used in isolation or as adjunct to other procedures. Releases tight lateral retinaculum and vastus lateralis. May be performed arthroscopically or as open procedure.
→ Medial plication – plication is the folding in and suturing of tucks. Tightening of medial structured (medial retinaculum, VMO).

→ Management – immobilised in extension splint (Richard splint) for 6 weeks, no active flexion for 6 weeks, extension or SLR for up to 6/52. Only static quads, generally WBAT.

→ Lateral release without tib tuberosity transfer - management:
o Early activation of quads and ROM exercises
o Mobilise FWB and progress exercises as pain and swelling allow.

Question 9

high tibial osteotomy

Answer 9

→ Aim – to divide the bone and reposition the fragments to realign the tibial and distribute weight bearing forces more evenly through the knee.
→ Advantages:
o Avoids internal disruption of tibiofemoral joint.
o Can later progress to TKR.
o Reduces OA pain.
→ Disadvantages:
o Causes considerable discomfort and long period of rehab.
o Not a cure for OA but may slow deterioration.
o Symptoms may reoccur.

Question 10

post operative management

Answer 10

→ Post operative management.
o Pain relief
o Commence circle-respiratory exercises day 0.
o Management can vary dependent on Dr.
o For example – commence rehab exercises day 1
 May SLR in Richard splint.
 If open wedge – restricted knee flexion 4-6 weeks and NWB.
 If closing wedge – may commence gentle knee flexion day 1 or 2 and mobilise day 1 – partial WB with Richard splint.

Question 11

factors associated with favourable results for arthroscopy knee

Answer 11

→ Factors associated with favourable results:
o <65 years of age or long-life expectancy.
o Not overweight (risk of failure/recurrence of deformity if overweight).
o 90 degrees flexion.
o <15 degrees flexion contracture.
o Higher activity level (HTO instead of TKR).
o Early uni-compartmental OA with corresponding varus or valgus deformity.
o Ligamentous stability
o Non-smoker.

Question 12

TKR

Answer 12

→ Prothesis is made up of femoral component, tibial component, polyethylene spacer, gold standard for treatment of severe OA.
→ ACL is removed, PCL is sometimes removed based on prothesis used (surgeons’ choice), MCL and LCL remain intact.

Question 13

complications of TKR and post op management

Answer 13

→ Complications:
o Fracture
o DVT or PE
o Infection
o Loosening of components
o Ongoing knee pain.
o Stiffness, reduced ROM.

→ Post-operative management
o Goals:
 Knee flexion >/= 90 degrees
 Knee extension 0 degrees.
 SLR
 Independence with HEP
 Independent mobility on stairs.

Question 14

uni-compartmental knee replacement

Answer 14

→ Procedure similar to TKR, however only one compartment is replaced.
→ Other compartment must be healthy.
→ Rehab can be quicker than TKR.
→ Aim up to 120 degrees flexion.

Question 15

optimizing total knee replacement

Answer 15

→ Patient education and expectations – consistent messaging from all staff.
→ Anaemia management HB – 120F and 130M.
→ Nutritional status
→ Weight loss – BMI under 40
→ Smoking cessation
→ Chronic opioid use weaning.
→ Liberal fasting, carbohydrate loading drink.
→ Commence discharge planning.
→ Prehab – exercises.

Question 16

peri and post operative complications of TKR

Answer 16

→ Perioperative – low dose spinal anaesthesia. – no IDC.
o High volume local anaesthetic joint infiltration.
 Adrenalin, NSAID, morphine, clonidine, dexamethasone.
o Motor sparing peripheral nerve block.
 Adductor canal block.
o Tranexamic acid
o Choice of surgical approach and prothesis.

→ Postoperative
o Early mob – day of surgery.
o No pjs.
o Daily goals
o Multi-modal analgesia
 Panadol, NSAID COX2, pregabalin
 Alexia SR/IR.

Question 17

ACL reconstruction

Answer 17

→ Indications to have surgery – significant functional disability due to instability.
→ Options for reconstruction
o Intra-articular reconstruction
 Auto-grafts (hamstrings, patella tendon) – graciliis or semitendinosis graft, or bone patella tedon.
 Allografts (cadaver)
 Synthesis grafts (LARS).

→ Hamstring grafts
o Advantages – good graft strength and no anterior knee pain.
o Disadvantages – evidence of elastic creep in graft due to poorly aligned collagen fibres may produce slightly lax graft & hamstring tears in the return to running phase.
→ Patella tendon
o Advantages – strong, biological eventually replaced by new tissue.
o Disadvantages – anterior knee pain and donor site pathology (fracture of patella or tib tubercle).

Question 18

allografts

Answer 18

Allografts
→ Advantages - no donor site pathology, shorter operation, eventually fully replaced by new tissue.
→ Disadvantages – graft rejection, allograft ruptures (especially using grafts from older donors).

Question 19

synthetic grafts

Answer 19

Synthetic grafts
→ There is great appeal for synthetic grafts to replace torn ACL.
→ Several synthetic ligaments have come and gone but non have met qualifaicationa needed for lasting ACL substitute.
→ Examples – Dacron, carbon fibre and gortex grafts.
→ LARS (ligament advancement re-enforcement system)
o Quicker return to function, sport.
o No difference at 24 months.

Question 20

physio management of ACL recon

Answer 20

→ Physiotherapy management
o Post-op presentation
 Knee bandages and Richard’s splint or ROM brace.
o Rehab exercises – largely surgeon protocol driven.
 Commence circulo-respiratory exercises if indicated day 0.
 Co-contraction exercises.
 Active-assisted knee flexion (aim 45-60 degrees on D/C and 60-90 degrees at 2 weeks).
 Mobilise on crutches – WB status surgeon dependent.
 Follow up on physio within 1-2/52.

Question 21

toe graft surgery

Answer 21

Toe grafts surgery
→ Procedure – example of osteotomy of 1st metatarsal valgus.
→ Management – patient mobilized with surgical shoe (HWB), walking aid not essential but may require a stick or crutches depending on balance and pain.