Case 44
Edward Schwarz, Tomos Richards in Cases of a Hollywood Doctor, 2019
Simple treatment begins with analgesia and lifestyle modification. This consists of simple painkillers like paracetamol and anti-inflammatories such as ibuprofen. Weight loss helps reduce joint reaction forces on weight-bearing joints and will aid symptoms. Bracing or splinting may help depending on the joint involved, and even intra-articular injection of steroid and local anaesthetic can be given to give temporary relief of an acute flare-up. When these methods fail there are three major categories of surgical options, dependent on the joint involved and patient factors: Osteotomy involves cutting the bone and realigning the mechanical axis of the joint to offload contact pressures on the degenerative portion of the joint; it is usually used in early disease and young patients.Arthrodesis (fusion) involves removing the joint surface and making the bones around the joint heal to each other to relieve pain at the expense of movement. This is commonly used in the hand and ankle.Arthroplasty is removal of the joint with interposition of another material in the joint space such as a hip or knee prosthesis. This is common in the hip and knee and has excellent results in relieving pain whilst preserving movement.
Surgery of the Shoulder
Timothy W R Briggs, Jonathan Miles, William Aston, Heledd Havard, Daud TS Chou in Operative Orthopaedics, 2020
Shoulder arthroplasty can be used to effectively treat advanced degenerative joint disease and unreconstructable trauma cases. The three main types of arthroplasty are humeral hemiarthroplasties, anatomic total shoulder replacements and reverse polarity shoulder replacements. The indication, age of the patient and integrity of the rotator cuff are all important in deciding between the types. Hemiarthroplasties are essentially a humeral replacement of the total anatomical replacement leaving the glenoid intact, and thus are not considered further. Reverse polarity shoulder replacements are indicated in cuff-deficient shoulders. They replace the humeral head with a socket and the glenoid with a glenosphere, with an aim of shifting the centre of rotation of shoulder medially and inferiorly, thus improving the lever arm of the deltoid.
Perioperative and Postoperative Deaths
Julian L Burton, Guy Rutty in The Hospital Autopsy, 2010
In patients undergoing an elective total hip replacement, the 90-day postoperative mortality rate is 0.08–0.55 per cent (Seagroatt et al., 1991; Dearborn, 1998; Parvizi et al., 2007; Ayanardi et al., 2009). Deaths during the surgery are rare. Most deaths associated with total hip arthroplasty are due to cardiovascular complications, and the risk of death rises with male sex, increasing age, increasing body mass index, co-morbidities, and simultaneous bilateral hip replacement (Seagroatt et al., 1991; Parvizi et al., 2001; Ayanardi et al., 2009). The risk of death is greater in those undergoing hip arthroplasty for an acute fracture, and Parvizi et al. (2004) report a 30-day mortality rate of 2.8 per cent for such cases. However, 58 per cent of patients suffering life-threatening complications had no risk factors. Most fatal complications arise within 4 days of surgery (Parvizi et al., 2007).
Understanding outcomes and toxicological aspects of second generation metal-on-metal hip implants: a state-of-the-art review
Published in Critical Reviews in Toxicology, 2018
Michael Kovochich, Brent L. Finley, Rachel Novick, Andrew D. Monnot, Ellen Donovan, Kenneth M. Unice, Ernest S. Fung, David Fung, Dennis J. Paustenbach
Hip arthroplasty is a surgical procedure in which diseased cartilage and bone of the hip joint are surgically replaced with prosthetic components (Learmonth et al. 2007). This procedure has long been considered a major medical benefit that can improve the quality of life for individuals with a hip joint disability and has been characterized as the “operation of the century” (Learmonth et al. 2007, p. 1508). Hip arthroplasty is most commonly used to treat osteoarthritis, rheumatoid arthritis, avascular necrosis, post-traumatic arthritis, certain hip fractures, benign and malignant bone disease, and Paget’s disease (AAOS (American Academy of Orthopaedic Surgeons) 2011b; NHS 2012; AAOS 2013). More than one million new hip prostheses are implanted each year worldwide, of which an estimated 400,000 are implanted in the US (Polyzois et al. 2012; USFDA 2012). Over the last 20 years, the success of hip arthroplasty and implant design improvements in older patients has led surgeons to perform this procedure in younger and more active patients (MacDonald 2004; Zywiel et al. 2011).
High rate of reoperation and conversion to total hip arthroplasty after internal fixation of young femoral neck fractures: a population-based study of 796 patients
Published in Acta Orthopaedica, 2019
David J Stockton, Lyndsay M O’Hara, Nathan N O’Hara, Kelly A Lefaivre, Peter J O’Brien, Gerard P Slobogean
Implant removal notwithstanding, hip arthroplasty (THA and hemiarthroplasty) accounted for 32% of reoperations while hip-preserving procedures (nonunion fixation, revision fixation, bone grafting, and osteotomy) accounted for 14%. An arthroplasty procedure typically denotes an unsalvageable joint, most likely due to advanced osteonecrosis or nonunion. With regard to nonunion, some surgeons in British Columbia may treat difficult cases with arthroplasty; however, in many cases the first option for an aseptic nonunion is a hip-preserving procedure. Revision fixation using a valgus-producing trochanteric osteotomy is a recommended treatment for nonunion in high Pauwels angle fractures (Deakin et al. 2015). Our results suggest that this technique may actually be quite rare (0.8%); however, we suspect that surgeons tended to bill this procedure as a “nonunion fixation” instead of an “osteotomy.” Nonunion after fracture of the young femoral neck is unique in that the treatment may involve an osteotomy, a fact that the surgical billing codes do not account for. In this instance, it is likely that surgeons chose to bill using a code that represented the indication for the procedure.
Disease activity affects the recurrent deformities of the lesser toes after resection arthroplasty for rheumatoid forefoot deformity
Published in Modern Rheumatology, 2021
Taro Kasai, Gen Momoyama, Yuichi Nagase, Tetsuro Yasui, Sakae Tanaka, Takumi Matsumoto
Resection arthroplasty, developed by Hoffmann in 1912 [6], has been widely used for RA forefoot deformities and has had various modifications [7–11]. In recent years, there has been a trend toward joint preservation instead of resection, with a view to maintain joint function, which can be possible owing to recent advances in the pharmacological treatment of RA [12,13]. Several studies on joint-preserving arthroplasty for RA forefoot deformity have shown good clinical results in patients with tightly controlled RA disease activities [14,15] or mild to moderate destruction of the metatarsal heads [12]. On the other hand, clinical results of joint-preserving arthroplasty for patients with high RA disease activities or whose joints are severely destroyed have not been fully elucidated. Therefore, resection arthroplasty has been left as a means for patients with high RA disease activity who might be at a risk of recurrent deformities if the joints are preserved or in those with limited physical function and do not require the forefoot push-off mechanism. However, it is questionable whether the outcome of resection arthroplasty is reliable even in patients with high disease activity. Although it has been well established that RA disease activity is closely related to the progression of primary deformities, especially in small joints such as those of the hand and foot [16,17], the relationship between RA disease activity and recurrent deformities after forefoot surgery has not been elucidated yet.