operative orthopaedics

orthopedic operations
د. عادل الهنداوي licture-6-


preparations:
1-planning: preop. measurement by: x-ray, 3d ct, mri, transparent
template, paper cut-out or artificial bones recently, 3d computer-assisted surgery:
it helps reviewing the procedure on 3d image & it s results preoperatively.
2-equipments: drill, osteotome, saw, chisel, gouge, plate &screws &
special instruments for certain operations(like joint replacement).
3-intra-operative radiography: to check reduction &position of the implant using x-ray cassettes or image intensifier &fluoroscopy giving real-time x-ray
pictures or even 3d reconstruction & mri pictures.
4- magnification: either using loupes (2-6 times) or operating microscope for nerve or small vessels repair.
5-blood-less field: for rapid &accurate operation, a tourniquet can be
used: either pneumatic cuff or rubber (esmarch s) bandage.
exsanguinations: means squeezing blood from distal to
proximal. the maximum tourniquet pressure is 150mmhg
above systolic blood pressure. the max. time is 3 hours.
6- skin preparation:
*skin shaving (if necessary) should be in the theater.
skin cleaning: by soap or cleansing agents(based on
alcohol, iodine or chlorhexidine) especially in open trauma.
drapes: the best is plastic adhesive drapes.
7- gown, gloves &masks:
gowns: should be made of occlusive materials.
gloves: use one or even better 2 pairs.
masks: face-mask is to protect the wound from dropinglets of
nearby personnel.
8-measures to reduce the risk of infection:
by: a- ultra-clean air system
b- reduce time of operation
c- ? number of people in the theatre
d- pre-, intra- &post-operative antibiotics.
9- surgeon protection:
hepatitis-b? vaccine.
hepatitis-c &hiv? use mechanical protection by:
a- protective clothing b- gloves c- eye protection.
10-thromboprophylaxis: to ? the risk of dvt, pulmonary embolism &chronic venous insufficiency in high risk group like: old age, obese &those with history
of previous thrombosis.
operations on bones:
osteotomy: is surgical division of bone to: correct a deformity, change the
shape of bone or to ? pain in oa by redirecting the load across a joint.
the site is near the deformity the amount of correction should be measured carefully the method is either closing or open wedge osteotomy & the
fixation can be achieved by casting, internal or external fixation.
complication: 1-general complications 2-under or over
correction 3-nerve injury 4-compartment syndrome 5-non-union.

bone fixation: can be done by: screws, kirschner-wire, malleable wire, staples, plate &screws, intramedullary nail, external fixator or a combination of them. all these will lose or break unless bone union occurs.

bone graft: needs clean vascular bed for incorporation. it acts by:

1-osteoinduction: stimulation of osteogenesis by bone morphogenetic protein(bmp) in the graft matrix &by the living surface bone cells on the graft.

2-osteoconduction: means the graft fill the bone defect &act as a scaffold on which new bone can form.
indications: 1-nonunion 2-bone loss due to trauma or tumor 3-arthrodesis.

types: the autogenous cancellous graft is the most commonly used graft.
1-autograft: from the patient himself e.g. cancellous (from ilium, upper
tibia, lower radius), cortical (iliac crest) or vascularized graft with it s
blood vessels(fibula, iliac crest, radius).
2-allograft: from other alive or dead person (can be stored in bone bank).
3-xenograft: from cows or pigs.
4-artificial bone.


leg length equalization:
causes of leg length inequality:1-congenital anomaly 2-mal united # &bone loss 3-physal injury 4-infection 5-paralysis.
a short limb may causes: limping, pelvic tilt, compensatory scoliosis
&backache.
if the shortening is < 2.5cm, it will be compensated &needs no surgical ?. if > 2.5 cm, it can be treated either by:
1-shortening the longer leg:
in adult: excise segment of bone.
in children: epiphysiodesis (growth plate stapling).
2-lengthening the shorter leg:
bone lengthening(callotasis or chondrodiastasis).
complications: 1-neurovascular injury 2-joint contracture
3-in children: over or under correction & angular deformity.
*bilateral leg lengthening can increase stature in short persons.

operation on joints:
arthrotomy: is surgical opening of a joint. the indications are:
1-drain an abscess 2-synovial biopsy 3-synovectomy 4-remove
a loose body or damaged structure like torn meniscus.

arthrodesis: is surgical fusion of a joint.
indications: for painful &/or unstable joint where movement can be sacrificed e.g. ankle, wrist, spine & sometime the knee &shoulder but rarely the hip.
method: remove the articular cartilage? appose the bone
ends &fix with internal or external fixation plus bone graft.
complications: 1-undesired position 2-nonunion.

arthroplasty: is surgical refashioning of a joint to relieve pain &preserve
movement.
types: 1-excisional arthroplasty: excise enough bone to create a gap making a false joint.
2-partial joint replacement: excise one articular surface like moore s
prosthesis for femoral neck #.
or one compartment is replaced like medial or lateral knee compartment.
3-total joint replacement: both articular surfaces are replaced by
prosthetic implant: the convex part is metal while the concave is
polyethylene. fixation is either by bone cement or cementless press-fit.

microsurgery: the indications are:
1-repair of nerve or vessel
2- toe transfer for amputated thumb
3-bone graft with vascular pedicle
4-replantation: of severed limb or digit.


amputation: is the 1st step of rehabilitation.
indications:
dead or dying? peripheral vascular disease(90%). severe trauma, burn,
frostbite.
dangerous? malignant tumor potentially lethal sepsis(gas gangrene)
crush injury(crush syndrome)
damn nuisance? when retaining a limb is worse than no
limb because of pain, gross malformation, recurrent sepsis,
loss of sensation(with pressure ulcer) or severe loss of function.

technique: a tourniquet is used unless there is arterial insufficiency.
skin? adequate equal anterior &posterior flap. for below knee
use long posterior flap.

muscle? are sutured over bone end to each other &to the periosteum.

nerves? are cut proximal to bone end.

bone? for below knee: fibula is cut 3cm shorter than tibia.

vessels? main vessels are tied & control any bleeding point.

skin? is closed without tension over a drain with firm bandage.

aftercare? repeat bandaging till have a conical stump.
encourage muscle exercise. joints should be
kept mobile &start using the prosthesis early.


level of amputations:
forequarter (interscapulothoracic) amputation: done for malignant tumor.

shoulder disarticulation: if humerus head is left? better appearance.
if 2.5cm of humerus can be left? can hold a prosthesis.

below elbow(transradial) amputation.

hindquarter (hemipelvectomy) amputation.

hip disarticulation: if head, neck &trochanters
can be left? can fit a prosthesis.
transfemoral amputation: at least 12cm
should be left for knee mechanism.
through knee amputation: for vascular disease & for children.

below knee(transtibial) amputation: if <3cm stump? slip.
at least 5- 6cm a stump to fit a prosthesis.
the ideal is 14cm, if longer? it has no advantage.

above ankle(syme s) amputation: just above the malleoli &
the fibrofatty tissue of the heel should stuck to the bone ends.
partial foot amputation:
through midtarsal joint(chopart),
through tarsometatarsal joints(lisfranc),
through metatarsal bones,
through mpj or better through proximal phalanx,
ray amputation: toe + it s metatarsal (for diabetic).
prostheses:
a prosthesis must fit comfortably, function well &look presentable.
it should also be used early.
electrically powered prosthesis for the upper limb has developed.
in the lower limbs, the weight is transmitted through:
ischial tuberosity, patellar tendon, upper tibia or through soft tissue.
recently, a total contact prosthesis is more comfortable.
complications of amputation stumps:
early:
1-secondary hemorrhage: due to infection.
2-breakdown of skin flap: due to ischemia or
suture under excessive tension.
3-gas gangrene: may occur in high thigh amputation
if the site is contaminated from the perineum
especially if the stump is ischemic.

late:
1- skin: eczema & tender inguinal ln, ?? rest from prosthesis.
ulceration due to ischemia, ? ? re-amputation at higher level.
2-muscle: if too much is left at the stump, it leads to unstable
cushion &insecure prosthesis, ?? excise the excess tissue.

3-artery: poor circulation may lead to ulceration, ??
re-amputation.
4-nerve:
tender neuroma, ?? the nerve should be cut more proximally
&buried within the soft tissue away from pressure points.

phantom limb: is feeling of amputated limb is still present, later this recedes or disappears. a painful phantom limb is difficult to treat, though, intermittent percussion to the end of the stump may help.

5-joint: the joint proximal to the stump may be stiff
or deformed e.g. knee fixed flexion in below knee
amputation which makes walking difficult.

6-bone:
bony spur: usually painless, if there is infection it may
become larger &painful, ?? excision of bone end with spur.

fracture: if the bone is transmitting little weight, it become
osteoporotic & may fracture, ?? orif.