Operative Management

Avraham Schulgasser

I. GOALS OF SURGERY AND OUTCOME EXPECTATIONS

There are numerous reasons to perform orthopaedic surgery which are usually categorized as elective or nonelective cases. Elective cases are nonemergent and for the most part aim at improving quality of life in one way or the other. Nonelective cases are generally urgent or emergent, but also serve to improve quality of life while possibly preventing or delaying further progression of injury or disease process. The primary goals of surgery are: restoration of anatomic parameter status postinjury, infection control, pain relief, return to baseline functional level, and prevention of further damage.¹

Restoration of proper anatomic parameters encompasses a variety of cases such as fracture repair and repair of congenital or acquired malformation. In cases of a displaced fracture, surgery is beneficial, in that once fracture reduction and limb alignment are restored functional recovery generally follows. A fracture that heals incorrectly can drastically reduce range of motion to the affected limb or joint, limiting the ability to perform ADLs. By restoring anatomic parameters, surgery may often help prevent or delay the onset of posttraumatic arthritis that may occur with fractures involving joints (intra-articular).² For congenital abnormalities, surgical correction may help reduce or eliminate some of the long-term complications that once, years ago, might have been irreparable.

In the case of open wounds (Figure 6-1) or in the setting of established musculoskeletal infection, surgical debridement is needed to reduce the incidence or treat the cause of contamination. This
includes irrigation and debridement of open wounds and septic joints or removal of hardware or implants when infection is present. In some cases, it is essential to remove the affected hardware because oral and intravenous antibiotics cannot penetrate foreign bodies to eliminate an infection. Multiple surgeries may be required depending on the situation. Once the infection clears, revision prostheses or hardware may be needed in order to fix the fracture or joint.

Figure 6-1 Open wound. An open wound requiring surgical debridement.

Pain relief is probably the most common indicator for surgery. A prime example of this is total joint arthroplasty. Patients with debilitating arthritis can get significant relief with joint replacement surgery. Additionally, in cases where patients previously underwent surgery to repair a fracture and now have discomfort from the implanted hardware, a removal of hardware may provide much needed pain relief. Additional situations in which pain relief is the primary goal include discectomy and spinal fusion for back and lower extremity pain and neurolysis for neuropathic pain syndromes.

Another indication for orthopaedic surgical intervention is prevention or delay of further injury progression. Some cases include unstable fracture patterns that without fixation will ultimately heal in malunion.³ Carpal tunnel/cubital tunnel release surgery works to prevent progression of nerve injury, and tumor removal to prevent further spread of cancerous lesions.⁴

Patient expectations can vary depending on the nature of the need for surgery whether it be restorative, to control infection, for pain relief, or to inhibit progression. More complex injuries may have a less favorable outcome than simpler ones. Patients with advanced stages of arthritis will have a longer road to recovery than those with earlier stages. This may be due to inactivity of patients with advanced arthritis, which can lead to muscle atrophy. Additionally, in patients who develop contractures, it can take longer to regain mobility. It is important that the patient is aware of all of the relevant variables to prevent false expectations.⁵ As with all surgeries, there are inherent risks that patients must be made aware of. Although great lengths are taken to minimize all risks, disclosure and transparency are important, and patients must be informed of possible negative consequences.

The goal of all surgery is to have the patient ultimately emerge in a better state of health than prior to surgery. Many variables factor in, and these will play a large part in individual outcomes.

Timeline and Progression of Healing

The timeline and progression of healing vary greatly depending on the procedure performed and the condition of the patient preoperatively and postoperatively. Age, physical condition, emotional stability, and patient cooperation and compliance all play a part in the healing process. Patients who undergo simple joint replacements such as hips and knees might expect to be weight bearing within the first day or two after surgery. However, patients who undergo a tendon repair typically require weeks of immobilization followed by extensive physical or occupational therapy to allow for proper healing. Simpler procedures such as trigger finger and carpal tunnel release only require
a few weeks of recovery and often do not need any type of therapy. Fractures, depending on location and severity of the injury, will also vary in the length of time it takes before full healing is achieved. Just as patients must be apprised of the risks inherent in their specific surgery, so too should they be apprised of the realistic timeline range and successive recovery stages that they might expect.

II. CLEARANCE AND PREOPERATIVE TESTING

As with all patients, a thorough history is an essential component of the patient examination. In the surgical patient, this is especially critical to ensure that all appropriate measures are taken prior to surgery. A thorough history and knowledge of preexisting medical conditions allow for the optimization of the patient prior to surgery and limit possible complications caused by unanticipated variables. Detailed history of prior anesthesia complications, as well as cardiac, pulmonary, endocrinology, and other pertinent medical comorbidities is essential.⁶

In emergent cases, preoperative clearances may be expedited and obtained by in-house medical providers. For elective cases, patients have more time and could typically be seen by their own health care providers. This of course will typically take more time to arrange and coordinate.

Depending on the patient, a specific set of preoperative tests are required (Table 6-1). Local policies and procedures as well as sound clinical judgment should be used on an individual patient-by-patient basis.

III. PREOPERATIVE CONSIDERATIONS AND INSTRUCTIONS

Skin Preparation

It is crucial to do a thorough skin examination of the area prior to surgery. It is important to note any prior surgical incisions or lesions that may fall in the path of the usual incision site. Sometimes

in the trauma patient, surgery will need to be delayed to allow for swelling to diminish and fracture blisters to heal prior to operating on a patient (Figure 6-2). This delay helps reduce possible wound complications.⁷ In elective cases where there is a preexisting skin condition, patients would be better served with a short course of treatment prior to surgery to help diminish any possibility of wound complications. Additionally, patients should be instructed to elevate and ice limbs whenever possible prior to surgery, specifically in trauma cases.

TABLE 6-1 Suggested Preoperative Testing Guidelines Based on Demographics and Comorbidities

Suggested Preoperative Testing Guidelines
	Medical Evaluation	CBC	UA	Coags	BMP	Hepatic Panel	CXR	EKG	Other
Age and Sex
Neonates-6 mo		X
Menarche-menopause		X							Urine pregnancy
50 and over		X						X
65 and over	X	X			X			X
Medical Condition
Cardiovascular and cerebrovascular disease	X	X			X			X
Pulmonary disease	X	X			X		X	X
Sleep apnea	X	X			X			X
Diabetes	X	X			X			X	HgbA1c
Hepatic disease	X	X		X	X	X		X
Renal disease	X	X	X		X			X
Bleeding disorder	X	X		X					Type and screen
BMI >40	X	X			X	X		X
Malignancy on chemo	X	X			X	X		X
HTN	X				X			X
Neuromuscular disease, seizures	X
Alcohol abuse				X	X	X
Hx anemia	X	X

Figure 6-2 Fracture blisters. Fracture blisters as evidenced by the fluid-filled vesicles and bullae overlying the fracture site.

In complicated cases where incisions involve areas of previous skin grafting, severe swelling, complex lacerations in the surgical field, areas where cosmesis is of concern, or general concerns regarding wound healing, a plastic surgeon should be consulted for further evaluation. Depending on the complexity, plastic surgeons may need to assist with the incision and closure of the surgical wound.

NPO

As part of the preoperative instructions patients should be advised to remain NPO prior to surgery. Typically, this means from midnight prior to surgery. In cases where surgery must be performed emergently or is scheduled for later in the day, refer to local policies and procedures in regard to NPO status.

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