Surgery Basics Of Joint Surgery

Front 1

What are the 3 goals in the treatment of joint disease?

Back 1

1) Relieve pain
2) Regain functional use
3) Arrest disease progression

Front 2

What type of cartilage is articular cartilage?

Back 2

Hyaline cartilage

Front 3

What are the 4 surgical treatments for joint disease?

Back 3

1) Arthroscopy
-diagnostic & therapeutic
2) Soft-tissue reconstruction
-luxation/subluxation
-ligament & other soft tissue repair/ replacement
3) fracture repair
4) joint replacement

Front 4

What are 2 reasons that articular cartilage heals poorly compared with other tissues?

Back 4

1) Poor regenerative response
2) Partial thickness defects & lesions greater than 5 mm (in horse) do not heal spontaneously
- Cartilage of younger heals better

Front 5

Damage to cartilage is common and can be a chronic degenerative form (_______) or an acute form.

Back 5

Osteoarthritis

Front 6

The outcome of cartilage repair is assessed based on what 3 things?

Back 6

1) Biochemical content
-including type II collagen & aggrecans
2) Histologic appearance
-relative to hyaline cartilage
3) functional outcome of joint & patient
-does it look like functioning normal in radiograph?

Front 7

What should you do if you are dealing with a partial thickness lesion in articular cartilage?

Back 7

Not debrided to full thickness, but fibrillated cartilage is removed (leaving intact cartilage below

Front 8

What do you do when you're dealing with a full-thickness lesion in articular cartilage?

Back 8

-debride until firmly attached cartilage is reached
-Edges are debrided to have sharp vertical edge
-Subchondral bone is debrided to subchondral bone plate (remove calcified cartilage that impedes repair process)
-necrotic bone is debrided to healthy bleeding bone

Front 9

What is arthroscopy useful for as a diagnostic tool?

Back 9

To identify soft-tissue lesions not visible with some imaging such as meniscal tears, cruciate ligament damage, cartilage fibrillation

Front 10

What are the 5 therapeutic uses of arthroscopy?

Back 10

1) Removal of fragments (OCD and fractures)
2) ASsistance w/ intra-articular fracture repair
3) Assessment & treatment of ligamentous injuries
4) Joint resurfacing
5) Thorough lavage- removes cartilage wear particles, cytokines & other inflammatory mediators
*Good for horses bc can't MRI

Front 11

What are 4 benefits of using arthroscopy instead of arthrotomy?

Back 11

1) Better visualization of joint
2) Less damage to joint capsule & surrounding tissues
3) Quicker return to use
4) Documentation of lesions and procedures (DVD, CD, still images)
-Arthroscopy has virtually replaced arthrotomy and treatment for equine joint disease

Front 12

What are the 7 athroscopic instruments?

Back 12

1) Arthroscope
2) Arthroscope sleeve
3) Obturators (sharp, blunt, conical)
4) Camera & light source
5) Sterile isotonic fluids & fluid line
6) Instruments
-probes, curettes, rongeurs, grasping forceps, elevators, blades, osteotomes
7) Egress cannula

Front 13

How do you perform joint distention when performing arthroscopy?

Back 13

Sterile isotonic fluid, but also possible w/ inert gas

Front 14

How do you insert the arthroscope and instruments for arthroscopy?

Back 14

Arthroscopic portal and instrument portals based on principle of triangulation
-put in from opposite sides

Front 15

What should you do before addressing the lesion when performing arthroscopy?

Back 15

Diagnostic visualization of the entire joint before addressing lesion(s)
-specific approaches vary w/ joint & site of lesion

Front 16

What are 7 procedures performed with an arthroscope?

Back 16

1) Diagnostic- to determine cause of distention or lameness
2) Removal of osteochondral fragments
3) Reconstruction of articular fractures
4) Synovectomy
5) Joint resurfacing
6) Arthrodesis
7) Lavage & debridement (septic joint)

Front 17

Do you want to remove small or large fragments first when removing osteochondral fragments? Why?

Back 17

Remove small fragments before large ones to maintain distension & visualization (large ones require large portals)

Front 18

What do you use to smooth the parent bone when removing osteochondral fragments?

Back 18

Hand curettage

Front 19

What is your next step after removing fragment and smoothing the parent bone when removing osteochondral fragments?

Back 19

Lavage and inspect to ensure all debris has been removed

Front 20

What is the prognosis of removing osteochondral fragments?

Back 20

Varies w/ joint, size, location in joint, number of fragments, chronicity, presence of other cartilage damage

Front 21

What are the 6 steps of reconstructing an intra-articular fracture?

Back 21

1) Debride loose debris from fracture gap
2) Reduce fracture, visualizing alignment of joint
3) Restore stability
4) Address any associated cartilage abnormalities
5) Most articular fracture repair using arthroscopy guidance are corrected w/ lag screw technique
6) **Correct anatomic alignment of the joint surface is essential for long- term success of intra-articular fractures

Front 22

What are 4 reasons to perform a synovectomy?

Back 22

1) To assist w/ visualization
2) To help w/ treatment of septic arthritis
-removal of synovium laden with fibrin, which may harbor bacteria
3) To augment treatment of chronic osteoarthritis
-removal of hypertrophied may reduce cytokine production & physical impingement
4) To control rheumatoid arthritis (not equine)
-Synovium is thought to be priary instigator and propagate cartilage deterioration

Front 23

What surgical method is typically used for a synovectomy?

Back 23

Motorized resector
-synovium regenerates over time

Front 24

What are 2 methods used for joint resurfacing?

Back 24

1) Stimulated endogenous repair
2) Articular grafting

Front 25

How is stimulated endogenous repair performed?

Back 25

Abrasion arthroplasty: debridement of lesion to subchondral bone plate then enter cancellous bone generally with microfracture technique, which allows access to cells and growth factors with destabilizing biomechanical strength of subchondral bone

Front 26

What are 2 sources for the graft for articular grafting?

Back 26

Osteochondral grafts
Cartilage cultures
-current area of research

Front 27

What is arthrodesis?

Back 27

Assisted fusion of a joint to alleviate pain and/or instability associated with movement

Front 28

When do you use arthrodesis for therapy? What joints?

Back 28

When joint is beyond any other treatment, best outcome with low motion joints (e.g. distal hock joints or proximal enterphalangeal joints in horses)
-salvage procedure w/ high motion joints

Front 29

What are 3 alternatives to arthrodesis?

Back 29

1) Joint replacement
-hip in SA
2) Excision arthroplasty
-hip & and shoulder in SA, possible hip in small LA
3) Amputation
-primarily SA

Front 30

How is arthrodesis generally accomplished?

Back 30

Internal fixation w/ removal of cartilage

Front 31

Explain how to remove cartilage when performing arthrodesis. Why do you remove the cartilage?

Back 31

Remove articular cartilage to bleeding subchondral bone
-enhances bone contact and promotes bony union
-contour opposing surfaces so they are congruent

Front 32

What internal fixation methods are appropriate for arthrodesis?

Back 32

Plates most stable
-cross, pins, screws, tension band wiring, ring fixators, external fixation alone or in combination, with or w/o external coaptation (bandage, splints, casts)

Front 33

In order to successfully accomplish arthrodesis _______ is needed, and compression is desirable.

Back 33

Rigid fixation

Front 34

Use of _________ can be used to promote healing and fill small defects when performing arthrodesis.

Back 34

Autogenous cancellous bone graft

Front 35

What can be used if additional cortical bone is needed when performing arthrodesis?

Back 35

Cortical grafts (rib or ilium) or commercial allografts (SA)

Front 36

What is the difference b/w arthrodesis and ankylosis?

Back 36

Ankylosis is when joints fuse on their own
-if vet or surgeon involved= arthrodesis

Front 37

What is a luxation? Subluxation

Back 37

A disturbance or disarrangement of the normal positioning of a bone at a joint
-luxation= joint no longer articulates
-subluxation: disturbance is incomplete & some portion of joint continues to articulate

Front 38

What are 4 clinical signs of luxations/subluxations?

Back 38

1) Abnormal apperance of affected joint w/ asymmetry compared w/ contralateral limb
2) Soft tissue swelling
3) Deviation of distal limb beginning at level of joint
4) Lameness and/or gait alteration

Front 39

What are 3 goals of treating a luxation/subluxation?

Back 39

1) Restore normal anatomic positioning
2) Stabilize the joint to prevent recurrence
3) Alleviate paint & restore function

Front 40

What does the outcome of luxation/subluxation treatment depend on?

Back 40

Joint affected, type of luxation, degree of soft tissue and/or bone damage, size of animal
-closed or open reduction
-soft-tissue reconstruction or internal fixation

Front 41

What are the 2 functionally distinct articulations of the stifle joint?

Back 41

Femorotibial & femoropatellar

Front 42

How many cavities are there in the stifle joint? How many communicate?

Back 42

3 cavities that intercommunicate

Front 43

What are 6 surgical conditions that occur in the stifle aside from osteochondral fragments and OCD?

Back 43

1) Cranial cruciate rupture
2) Meniscal injury
3) Caudal cruciate injury
4) Collateral ligament injury
5) Stifle luxation
6) Patellar luxation

Front 44

What are the 3 general types of repairs that can be done on a cranial cruciate rupture?

Back 44

1) Intra-articular reconstruction techniques
2) Extra-articular reconstruction techniques
3) TPLO

Front 45

What is the theory behind performing a TPLO?

Back 45

Provides stability during weightbearing by reducing cranial tibial trust without attempt to restore cranial cruciate ligament

Front 46

What can be done for treatment of meniscal injury?

Back 46

Preserve grossly normal meniscus
-excise (or possibly suture) damaged portions of meniscus

Front 47

True or false. Primary repair is feasible with cranial cruciate ligament rupture.

Back 47

False, not feasible

Front 48

What are 5 indications for a total hip arthroplasty?

Back 48

1) Osteoarthritis from hip dysplasia
2) Traumatic luxation
3) Irreparable fractures
4) Femoral head/ neck incision
5) Osteoarthritis
-use when other methods fail to maintain life & function

Front 49

What are the 2 goals of total hip arthroplasty?

Back 49

Alleviate pain
Restore fucntion

Front 50

Why do you want to perform total hip arthroplasty as LATE as possible?

Back 50

Longer the duration of the implantation, the greater the risk of complications