12 Orthopaedic surgery

Most Achilles tendon problems arise due to overuse injuries and are multifactorial. However, in a trauma setting a true rupture is the most common presentation.

There is still debate regarding open repair and the associated risk of wound complications (reported as up to 4%) and conservative splinting and the risk of re-rupture reported as 3.5% in operative patients versus 12% in non-operative patients.^1,2

Open repair is typically performed under general anaesthesia, with the patient prone. If the tendon ends can be approximated a primary repair is achieved and the skin closed with either absorbable subcuticular or non-absorbable sutures. Postoperative rehabilitation programmes vary with some groups preferring cast or brace immobilization for 6–8 weeks; however, the period of immobilization necessary has not been clearly defined.

Ankle fractures are a common injury among the young and elderly, often resulting from a combination of rotation and abduction or adduction forces. Stable fractures, i.e. those with isolated lateral malleolus fractures that are in a good position with an intact syndesmosis, may be managed conservatively. If there is failure to achieve or maintain reduction, or there is an unstable fracture pattern, operative intervention is indicated.

Open reduction and internal fixation should be planned once the soft tissues allow, i.e. swelling will allow soft tissue closure postoperatively and fracture blisters are intact or not near the planned incision. Fixation is often carried out with a locking compression plate or one-third tubular plate ± lag screw insertion. The medial malleolus can often be fixed with cannulated screws or partially threaded cancellous screws. The syndesmosis is checked and one or two screws inserted as needed if unstable. The case is usually performed under general anaesthesia with tourniquet control. Closure is with absorbable subcuticular sutures.

The anterior cruciate ligament (ACL) is integral in stabilizing the knee. The ACL-deficient knee has been linked to an increased rate of degenerative osteoarthritic changes and meniscal injuries. These injuries are most often a result of contact injuries with a rotational component and low-velocity, non-contact, deceleration forces.

Primary suture repair of the ACL used to be performed but due to failure rates of up to 100% it has now been abandoned for reconstructive techniques.

ACL reconstruction can be performed with the use of either autograft (bone-patellar tendon-bone or hamstring tendon autograft) or allograft tissue.¹ It is currently unclear if the outcomes of these two methods differ significantly. These techniques are usually performed using an arthroscopic approach under general anaesthesia.

Carpal tunnel syndrome results from compression of the median nerve as it enters the palmar surface of the hand under the flexor retinaculum. It typically presents with pain, paraesthesia, and hypoaesthesia over the radial three and a half fingers, often at night. Electrophysiological tests (nerve conduction studies) are often performed to support the clinical diagnosis.

Surgery usually involves local or regional anaesthesia as a day case. An incision is made over the flexor retinaculum with or without tourniquet control, with complete division of the retinaculum to ensure release. Closure is typically with interrupted non-absorbable sutures, and dressing with a bulky bandage and early mobilization.

Clavicle fractures are common fractures accounting for up to 12% of all fractures. They can be divided into lateral, middle, and medial third fractures, with approximately 80% being middle third fractures. Of middle third clavicle fractures, there is approximately 15% prevalence of non-union of fractures treated without surgery and a 2% rate of non-union of fractures treated with plate fixation.¹

Indications for operative treatment of acute midshaft clavicular fractures include open fractures, fractures with compromised skin due to severe fracture displacement (‘tented skin’), and fractures associated with vascular or neurological injury. Other acute fracture indications that are proposed are initial clavicular shortening of 2cm, and comminuted fractures with a displaced transverse fragment.

Lateral third fractures that do go on to form a painful/symptomatic non-union may require fixation with either a synthetic sling or a hook plate. The latter can limit shoulder abduction and will usually need to be removed at around 8 weeks.

The procedure is carried out under general anaesthesia, with plate or intramedullary fixation, with subcuticular absorbable sutures to close. A period of support from a sling postoperatively is usual with rehabilitation as per local protocol.

Distal radius fractures are a common injury, particularly in the elderly. Several options exist for treatment. Non-operative management consists of closed treatment with casting. Operative treatment options include Kirschner (K) wire insertion, external fixation, arthroscopic-assisted external fixation, and various methods of open reduction and internal fixation. Indications that have been suggested for operative intervention are radial shortening, >2mm articular step, volar tilt of >10°, and dorsal tilt >10°.

The operation is usually carried out under general anaesthesia with tourniquet control. The method of fixation is defined by the fracture pattern, and currently despite multiple prospective meta-analyses including a Cochrane review, no specific type of fixation has been proven to be advantageous.^1,2 The volar approach is favoured over a dorsal incision due to the soft tissue interposition between the plate and the tendons, minimizing adhesions. Skin closure is usually with absorbable subcuticular sutures.

Neck-of-femur fractures are relatively common. Approximately 50% are extracapsular. Fixation was traditionally with dynamic hip screw, with good long-term results. More recently the cephalomedullary devices have gained popularity, particularly with intertrochanteric and reverse oblique fractures; however, there is currently no consensus on which fixation method is better with a recent prospective blinded study showing no significant benefit of one treatment modality over the other.^1,2

The procedure is usually carried out on a traction table under general anaesthesia or spinal/epidural. The prosthesis is inserted and skin closure is with clips or subcuticular sutures.

The emphasis postoperatively is mobilization to help prevent further complications such as pressure sores and infections, which will severely increase morbidity. At this time bone-protecting agents, if not contraindicated, should be commenced.

Ganglions are commonly found on the dorsum of the hand over the scapholunate ligament (approx 70% of all ganglions) and are a mucinous filled cyst typically adjacent to joint capsule or the tendon sheath. They may present just as a soft swelling or can cause mild aching.

Options for treatment include aspiration and injection of hyaluronidase; however, the recurrence rate is approximately 50%.^1,2 Surgery for a dorsal ganglion usually involves local or regional anaesthesia as a day case. An incision is made directly over the ganglion, with the cyst being mobilized down to the joint capsule, with its capsular extensions then being excised. Closure is typically with interrupted non-absorbable sutures, and dressing with a bulky bandage and early mobilization.

Hallux valgus occurs with lateral deviation of the great toe and medial deviation of the first metatarsal. Commonly the deformity is characterized by progressive subluxation of the first metatarsophalangeal joint. Patients typically present with pain centred over the medial eminence caused by irritation of the dorsal cutaneous nerve of the great toe or an inflamed or thickened bursa overlying the area.

There are multiple operations available for the correction of hallux valgus, the details of which are outside the scope of this book;^1–3 however, the majority require an osteotomy. Closure is typically with interrupted non-absorbable sutures, dressing with a bulky bandage and walking is encouraged with a heel-bearing shoe. At approximately 6 weeks, metatarsophalangeal and interphalangeal joint movement is initiated.

Hip arthroscopy allows thorough visualization of the acetabular labrum, femoral head, and acetabular chondral surfaces, as well as of the fovea, ligamentum teres, and adjacent synovium. This procedure was initially only performed at specialist centres; however, like most advances in surgery, it is becoming more widespread although it remains technically complex.

Access to the hip joint is difficult because of the resistance to distraction resulting from the large muscular envelope, the strength of the iliofemoral ligament, and the negative intra-articular pressure. The procedure involves general anaesthesia, with the use of a traction table to distract the hip. A guide-wire and sequential dilation under image intensifier control allow suitable port placement. A number of therapeutic procedures can be carried out including removal of loose bodies, debridement of acetabular and femoral head chondral flap lesions, and repair of labral tears. At the end of the procedure, the arthroscopic fluid is drained out of the joint and the incisions are closed with sutures, skin glue or Steri-strips.

Postoperatively, patients can mobilize fully weightbearing as their pain allows, initially with crutches and without them after a few days.

Hip resurfacing arthroplasty involves removal of the diseased or damaged surfaces of the head of the femur and the acetabulum. The hip is then fitted with a non-cemented monoblock acetabular component combined with a metal-on-metal bearing made from cobalt-chromium alloy to form a pair of metal bearings. This is generally performed under general anaesthesia, with closure of the skin by subcuticular sutures or surgical clips.

The procedure was popularized by the reported ease of revision to total hip arthroplasty, the reduced risk of dislocation due to larger bearing size (0.05% in the first year), and decreased risk of loosening due to the use of metal-on-metal bearing surfaces, avoiding the wear debris associated with polyethylene. However, this is now being challenged with revision rates of 14% being reported.^1,2

Another concern with these devices is the possibility of metal degradation products being absorbed into the body and their local and systemic effects. The implications of this are presently unknown.

Supracondylar fractures of the humerus are a common paediatric injury. Classically Gartland II and III type fractures (displaced) are managed operatively, usually with closed reduction and percutaneous pinning. Gartland I type fractures (undisplaced) are managed conservatively with an above-elbow cast.

There is still debate regarding the wiring technique, with opinion split between lateral entry and medial/lateral entry. Lateral entry advocates state that there is a reduced risk of inadvertently damaging the ulnar nerve, while advocates of medial/lateral entry point to a possible benefit with increased mechanical strength.^1–3

The procedure involves general anaesthesia and K-wire insertion under image intensifier guidance. The wires are dressed and the elbow is immobilized in an above-elbow cast.

Knee arthroscopy is usually performed under general anaesthesia as a day case procedure. A small incision is made in the knee and saline is pumped into the joint space to facilitate visualization. An arthroscope, attached to a video camera is inserted through a second small incision. Some loose debris may be flushed out through the cannula along with the irrigation fluid, but consent must include the possibility for the need to carry out other procedures such as meniscal tear excision.

Debridement is often performed at the same time as washout; this involves the use of instruments to remove damaged cartilage or bone. At the end of the procedure, the saline is drained out of the joint, local anaesthetic is often added at this point and the incisions are closed with sutures, skin glue, or Steri-strips.

Elective THR is carried out to relieve discomfort and disability caused by arthropathies (including osteoarthritis and rheumatoid arthritis) of the hip. THR is considered to be one of the most effective orthopaedic procedures performed at the present time.

There are a number of surgical approaches to the hip, with the posterior approach remaining the most common for elective primary THR. There is good evidence to support the combined use of antibiotic impregnated cement and systemic antibiotics to reduce infection.^1–3 This is generally performed under general anaesthesia, with closure of the skin by subcuticular sutures or surgical clips.

There are a large number of prosthesis designs, bearing materials and fixation modalities. Many of these have specific complications, e.g. ceramic-on-ceramic bearing surfaces have an increased risk of squeaking and cracking. Metal-on-metal has the possible risk of metal ion exposure. The rate of revision as reported by the Swedish Joint Registry is approximately 6% at 7 years.

Severe pain and disability with accompanying radiological changes in the knee are almost always the indications for total knee arthroplasty, in patients where conservative treatment has failed or is futile. Occasionally there may be an indication to replace a knee because of progressive deformity and/or instability, and pain may not necessarily be the most significant factor.

This is generally performed under general anaesthesia. A midline incision is made with intraoperative tourniquet to aid the surgical field. There are multiple implants available, varying in fixation, whether cruciate sparing or sacrificing, constraint, and composition. Even though for a true total knee replacement all three compartments—medial, lateral and patellofemoral—are resurfaced, commonly, depending on surgeon preference or patella condition, the patellofemoral compartment may not be resurfaced.

There is good evidence to support the combined use of antibiotic impregnated cement and systemic antibiotics to reduce infection.^1,2 The routine use of drains is still a matter of debate. Closure of the skin is by subcuticular sutures or surgical clips.

Postoperatively the patient is either mobilized with physiotherapy or continuous passive movement machines immediately or on day 1 postoperatively.

For intracapsular fractures, the Garden classification is the most commonly used: I, incomplete; II, complete but non-displaced; III, complete, partially displaced; and IV, complete and fully displaced.¹

Classically displaced intracapsular neck of femur fractures are managed with hemiarthroplasty, either cemented or uncemented.² There is still debate about the use of cemented prosthesis and their potential for better functional results balanced with the risk of intraoperative hypotension.³ Total hip arthroplasty may be considered in those patients with good preoperative function and existing osteoarthritis; however, there are concerns over an increased risk of postoperative dislocation.

The bipolar prosthesis has a theoretical advantage in that it is designed to move on its inner bearing, in addition to articulating at the prosthesis–acetabulum interface. The purpose of this design is to achieve less acetabular wear, less pain, lower dislocation rates, and increased range of motion. However, bipolar prostheses are more expensive and it is still unclear whether or not the inner bearing loses mobility with time and becomes stiff, thereby minimizing the advantage of this design.

For intracapsular fractures, the Garden classification is the most commonly used: I, incomplete; II, complete but non-displaced; III, complete, partially displaced; and IV, complete and fully displaced.

Typically cannulated screws are used for undisplaced or minimally displaced intracapsular fractures, as the blood supply is likely to be sufficient, in patients with good-quality bone to prevent avascular necrosis, although this is still one of the major postoperative risks. The procedure involves the patient positioned on a traction table, then, with image intensifier guidance, insertion of three cannulated screws, usually positioned in an inverted triangle with the lowest screw being inserted above the lesser trochanter.

The wound is closed in layers with subcuticular sutures or surgical clips to the skin. Weightbearing status is usually partial to full.

Intramedullary nail fixation of a femoral fracture has become gold standard when compared with plate fixation or conservative treatment in the majority of cases. The benefits over plate fixation include reduction of extensive soft tissue dissection with the increased risk of infection and quadriceps scarring.

Intramedullary nailing can be performed as either retrograde or antegrade and can be reamed or unreamed. The debate surrounding reamed versus unreamed is ongoing.¹ The negative effects proposed for reaming are elevated intramedullary pressures, elevated pulmonary artery pressures, and increased fat embolism. However, reaming allows the use of larger nails and the overall outcome of bone growth and blood supply does not differ, with the latter being re-established at approximately 11 weeks.

Intramedullary nail fixation of a tibial shaft fracture has become gold standard when compared to plate fixation or conservative treatment in the majority of cases. Fractures close to the mortise, the knee and multisegmental fractures will likely benefit from plating or the use of external fixation devices.

Tibial intramedullary nails are often used in open fractures, using less soft tissue stripping, which allows concomitant soft tissue coverage. Conservative management of tibial fractures still has an important role to play in those who have significant comorbidities; however, nailing allows early mobilization, avoiding the stiffness of the ankle and the knee associated with full leg casting.¹

The debate surrounding reamed versus unreamed is ongoing. The negative effects proposed for reaming are elevated intramedullary pressures, elevated pulmonary artery pressures, and increased fat embolism. However, reaming allows the use of larger nails and the overall outcome of bone growth and blood supply does not differ with the latter being re-established at approximately 11 weeks.

Trigger finger results from localized tenosynovitis of the superficial and deep flexor tendons adjacent to the A1 pulley at the metacarpal head. This inflammation causes nodular enlargement of the tendon (commonly in the ring and middle fingers), causing a painful clicking as the nodule moves through the pulley.

Surgery usually involves local or regional anaesthesia as a day case. An incision is made over the A1 pulley with tourniquet control, care is taken to visualize the digital nerves and release the A1 pulley and then to assess if there is any further triggering. Closure is typically with interrupted non-absorbable sutures, and dressing with a bulky bandage and early mobilization.