Chapter 12: Surgical Interventions and Postoperative Management PDF

CHAPTER 12: SURGICAL INTERVENTIONS AND POSTOPERATIVE MANAGEMENT  INDICATIONS FOR SURGICAL INTERVENTION INCAPACITATING PAIN AT REST OR WITH ACTIVITY MARKED LIMITATION OF MOTION GROSS INSTABILITY OF A JOINT OR BONY SEGMENT JOINT DEFORMITY OR ABNORMAL ALIGNMENT...

CHAPTER 12: SURGICAL INTERVENTIONS AND POSTOPERATIVE MANAGEMENT  INDICATIONS FOR SURGICAL INTERVENTION INCAPACITATING PAIN AT REST OR WITH ACTIVITY MARKED LIMITATION OF MOTION GROSS INSTABILITY OF A JOINT OR BONY SEGMENT JOINT DEFORMITY OR ABNORMAL ALIGNMENT SIGNIFICANT STRUCTURAL DEGENERATION CHRONIC JOINT SWELLING FAILED NONSURGICAL OR PREVIOUS SURGICAL MANAGEMENT SIGNIFICANT LOSS OF FUNCTION LEADING TO DISABILITY AS THE RESULT OF ANY OF THE PRECEDING FACTORS  CONSIDERATIONS FOR PREOPERATIVE MANAGEMENT PREOPERATIVE EXAMINATION AND EVALUATION PAIN – LEVEL OF PAIN ACCORDING TO THE PATIENT RANGE OF MOTION AND JOINT INTEGRITY – AROM AND PROM MEASUREMENTS ALONG W/ ACTIVE JOINT MOTION AND STABILITY SKIN INTEGRITY – NOTE SCARS FROM PREVIOUS INJURIES OR SURGERIES MUSCLE PERFORMANCE – MUSCLE STRENGTH IN AFFECTED AREAS POSTURE – OBSERVE ANY POSTURAL ABNORMALITIES THAT MAY AFFECT ROM AND FUNCTION GAIT ANALYSIS – ANALYZE GAIT CHARACTERISTICS (ASSISTED DEVICES, DEGREE OF WEIGHT BEARING, ETC.) FUNCTIONAL STATUS – LIMITATIONS AND ABILITIES  CONSIDERATIONS OF PREOPERATIVE MANAGEMENT PREOPERATIVE PATIENT EDUCATION: METHODS AND RATIONALE OVERVIEW OF THE PLAN OF CARE – EXPECTED DURING THE POSTOPERATIVE PERIOD POSTOPERATIVE PRECAUTIONS – PRECAUTIONS OR CONTRAINDICATIONS TO POSITIONING, MOVEMENT, OR WEIGHT BEARING THAT MUST BE FOLLOWED POSTOPERATIVELY BED MOBILITY AND TRANSFERS – TEACH THE PATIENT HOW TO MOVE IN BED AND PERFORM WHEELCHAIR TRANSFERS SAFELY INITIAL POSTOPERATIVE EXERCISES – TEACH THE PATIENT ANY EXERCISES THAT WILL BE STARTED DURING THE VERY EARLY POSTOPERATIVE PERIOD DEEP-BREATHING AND COUGHING EXERCISES, ACTIVE ANKLE EXERCISES, OR GENTLE MUSCLE SETTING EXERCISES OF IMMOBILIZED JOINTS  CONSIDERATIONS OF PREOPERATIVE MANAGEMENT PREOPERATIVE PATIENT EDUCATION: METHODS AND RATIONALE GAIT TRAINING – TEACH PATIENT TO USE SUPPORTIVE DEVICES THAT MAY BE NEEDED PAIN MANAGEMENT – EDUCATE THE CORRECT USE OF CRYOTHERAPY FOR POSTOPERATIVE PAIN MANAGEMENT WOUND CARE – EDUCATE ON THE SIGNS OF INFECTION AND HOW TO CLEAN THE INCISION SITE AN EXTENDED PREOPERATIVE EXERCISE PROGRAM LIKELIHOOD THAT LEARNING WILL CARRY OVER AND EXERCISES WILL BE PERFORMED CORRECTLY FOLLOWING SURGERY, AND TO INCREASE THE LIKELIHOOD OF ACHIEVING OPTIMAL POSTOPERATIVE FUNCTIONAL OUTCOMES  CONSIDERATIONS FOR POSTOPERATIVE MANAGEMENT POSTOPERATIVE EXAMINATION AND EVALUATION CHECK FOR SIGNS OF REDNESS OR TISSUE NECROSIS ALONG THE INCISION(S) AND AROUND SUTURES PALPATE ALONG THE INCISION AND NOT SIGNS OF TENDERNESS AND EDEMA PALPATE TO DETERMINE EVIDENCE OF INCREASED HEAT CHECK FOR SIGNS OF DRAINAGE; NOTE COLOR AND AMOUNT OF DRAINAGE ON THE DRESSING NOTE THE INTEGRITY OF AN INCISION ACROSS A JOINT DURING AND AFTER EXERCISE AS THE INCISION HEALS, CHECK THE MOBILITY OF THE SCAR  CONSIDERATIONS FOR POSTOPERATIVE MANAGEMENT PHASES OF POSTOPERATIVE REHABILITATION MAXIMUM PROTECTION PHASE PROTECTION OF OPERATED TISSUES IS PARAMOUNT IN THE PRESENCE OF TISSUE INFLAMMATION AND PAIN MUSCLE SETTING EXERCISES TO PREVENT MUSCLE DISUSE ATROPHY ALSO ARE INDICATED. FEW DAYS TO 6 WEEKS DEPENDING ON THE TYPE OF SURGERY AND THE TISSUES INVOLVED MODERATE PROTECTION/CONTROLLED MOTION PHASE INTERMEDIATE PHASE WHEN INFLAMMATION HAS SUBSIDED, PAIN AND TENDERNESS ARE MINIMAL, AND TISSUES ARE ABLE TO WITHSTAND GRADUALLY INCREASING LEVELS OF STRESS PROGRESSION TO THIS PHASE INCLUDE THE ABSENCE OF PAIN AT REST AND THE AVAILABILITY OF AT LEAST LIMITED PAIN-FREE MOVEMENT OF THE OPERATED EXTREMITY BEGINS 4-6 WEEKS POSTOP AND LASTS AN ADDITIONAL 4-6 WEEKS MINIMUM TO NO PROTECTION/RETURN TO FUNCTION PHASE FULL (OR ALMOST FULL) PAIN-FREE ACTIVE ROM SHOULD BE AVAILABLE AND THE JOINT CAPSULE (IF INVOLVED) SHOULD BE CLINICALLY STABLE BEGINS 6-12 WEEKS POSTOP AND MAY CONTINUE UNTIL 6 MONTHS POSTOP OR BEYOND  CONSIDERATIONS FOR POSTOPERATIVE MANAGEMENT TIME-BASED AND CRITERION-BASED PROGRESSION CAN VARY DRAMATICALLY DEPENDING ON THE PROCEDURE. DETERMINING THE PATIENT’S READINESS TO ADVANCE FROM ONE PHASE OF POSTOP REHAB TO THE NEXT SHOULD BE BASED ON TIME BUT ALSO ON THE ABSENCE OF PAIN, RESTORATION OF A PARTICULAR AMOUNT ROM OF LEVEL STRENGTH. PUTTING POSTOPERATIVE REHABILITATION INTO PERSPECTIVE KEY TO SUCCESSFUL POSTOP OUTCOMES IS EFFECTIVE, LONG- TERM PATIENT SELF-MANAGEMENT THERAPIST DIRECTED, EARLY POSTOP PATIENT EDUCATION FOLLOWED BY A HOME PROGRAM OF SELECTED INTERVENTIONS CAREFULLY TAUGHT AND ARE PERIODICALLY MONITORED AND MODIFIED BY THE THERAPIST DURING EACH PHASE OF REHABILITATION  POTENTIAL POSTOPERATIVE COMPLICATIONS AND RISK REDUCTION POTENTIAL POSTOPERATIVE COMPLICATIONS AND RISK REDUCTION PULMONARY COMPLICATIONS RISK OF PNEUMONIA OR ATELECTASIS (COLLAPSED LUNG) EARLY STANDING AND AMBULATION FOLLOWING SURGERY MAY REDUCE THE RISK DEEP VEIN THROMBOSIS AND PULMONARY EMBOLISM BLOOD CLOTS JOINT SUBLUXATION OR DISLOCATION RISK CAN BE REDUCED THROUGH PATIENT EDUCATION AND EXERCISE INSTRUCTION RESTRICTED MOTION FROM ADHESIONS AND SCAR TISSUE FORMATION MOVEMENT OF THE OPERATED AREA AS EARLY AS POSSIBLE AFTER SURGERY W/ ROM EXERCISES OR CONTINUOUS PASSIVE MOTION W/IN A SAFE RANGE TO HELP PREVENT CONTRACTURES. FAILURE, DISPLACEMENT, OR LOOSENING OF INTERNAL FIXATION DEVICE EXCESSIVE OR PREMATURE WEIGHT BEARING PRIOR TO READINESS FROM INCOMPLETELY HEALED TISSUES, BONE, OR OTHER STRUCTURES  DEEP VEIN THROMBOSIS (DVT) AND PULMONARY EMBOLISM (PE) COMPLICATION AFTER MUSCULOSKELETAL INJURY OR SURGERY, PROLONGED LIMB IMMOBILIZATION, OR BED REST AND IS ATTRIBUTED TO VENOUS STASIS, INJURY TO AND INFLAMMATION OF THE WALLS OF A VEIN, OR A HYPERCOAGULABLE STATE OF THE BLOOD DVT: SIGNS AND SYMPTOMS DULL ACHING OR SEVERE PAIN, SWELLING, OR CHANGES IN SKIN TEMPERATURE AND COLOR, SPECIFICALLY HEAT AND REDNESS WHEN SUSPECTED, MEDICAL TESTING SHOULD BE INITIATED TO CONFIRM OR RULE OUT THE CONDITION. ULTRASONOGRAPHY, VENOUS DUPLEX SCREENING, OR VENOGRAPHY PE: SIGNS AND SYMPTOMS SUDDEN ONSET OF SHORTNESS OR BREATH, RAPID AND SHALLOW BREATHING, AND CHEST PAIN LOCATED AT THE LATERAL ASPECT OF THE CHEST THAT INTENSIFIES W/ DEEP BREATHING AND COUGHING. SWELLING IN THE LOWER EXTREMITIES, ANXIETY, FEVER, EXCESSIVE SWEATING, A COUGH, AND BLOOD IN THE SPUTUM IMMEDIATE MEDICAL REFERRAL IS WARRANTED FOR A DEFINITIVE DIAGNOSIS AND MANAGEMENT  DEEP VEIN THROMBOSIS (DVT) AND PULMONARY EMBOLISM (PE) REDUCING THE RISK OF DVT PROPHYLACTIC USE OF ANTICOAGULANTS THERAPY (HIGH RISK PATIENTS) ELEVATING LEGS WHEN LYING SUPINE OR WHEN SITTING NO PROLONGED SITTING INITIATE EARLY AMBULATION ACTIVE “PUMPING” EXERCISES COMPRESSION STOCKINGS SEQUENTIAL PNEUMATIC COMPRESSION UNIT FOR PATIENTS ON BED REST MANAGEMENT OF DVT: ACUTE CARE MANAGEMENT ADMINISTERING ANTICOAGULANT MEDICATION, PLACING THE PATIENT ON BED REST, ELEVATING THE INVOLVED EXTREMITY, AND USING GRADUATED COMPRESSION STOCKINGS MANAGEMENT OF DVT: POSTHOSPITALIZATION PRECAUTIONS TYPICALLY CONTINUES ON AN ANTICOAGULANT MEDICATION FOR ABOUT 6 MONTHS HAS TO AVOID CONTACT SPORTS, RUNNING, AND SKIING MANDATORY HELMET USED DURING HIGH “FALL RISK” ACTIVITIES  COMMON ORTHOPEDIC SURGERIES OPEN PROCEDURES INCISION OF ADEQUATE LENGTH AND DEPTH THROUGH THE NECESSARY SUPERFICIAL AND DEEP LAYERS OF SKIN, FASCIA, MUSCLES, AND JOINT CAPSULE THAT ALLOWS THE OPERATIVE FIELD TO BE FULLY VISUALIZED ARTHROTOMY – JOINT CAPSULE IS INCISED TO EXPOSE JOINT STRUCTURES ARTHROSCOPIC PROCEDURES USED AS A DIAGNOSTIC TOOL AND AS A MEANS OF TREATING A VARIETY OF INTRA-ARTICULAR DISORDERS AND ARE TYPICALLY PERFORMED ON AN OUTPATIENT BASIS AND OFTEN UNDER LOCAL ANESTHESIA INCLUDE LIGAMENT, TENDON, AND CAPSULE REPAIRS OR RECONSTRUCTION, JOINT DEBRIDEMENT, MENISCECTOMY, ARTICULAR CARTILAGE REPAIR, AND SYNOVECTOMY ARTHROSCOPICALLY ASSISTED PROCEDURES (“MINI-OPEN”) USES ARTHROSCOPY FOR A PORTION OF THE PROCEDURES BUT ALSO REQUIRES AN OPEN SURGICAL FIELD FOR SELECTED ASPECTS OF THE OPERATIVE PROCEDURE ROBOTIC-ASSISTED PROCEDURES ARTHOSCOPR  TISSUE GRAFTS AUTOGRAFT GRAFT IS THE PATIENT’S OWN TISSUE HARVESTED FROM A DONOR SITE IN THE BODY RISKS ASSOCIATED INCLUDE THE NEED FOR TWO SURGICAL PROCEDURES AND THE POTENTIAL FOR NEGATIVE CONSEQUENCES AT THE DONOR SITE ALLOGRAFT USES FRESH OR CRYOPRESERVED TISSUE THAT COMES FROM A SOURCE OTHER THAN THE PATIENT – CADAVERIC DONOR RISKS INCLUDE DISEASE TRANSMISSION FROM THE DONOR, COMPROMISED GRAFT STRENGTH RESULTING FROM STERILIZATION, AND FAILURE SECONDARY TO IMMUNOLOGICAL REJECTION SYNTHETIC GRAFTS GRAFT THAT IS AN ALTERNATIVE TO HUMAN TISSUE AND HAVE BEEN USED ON A LIMITED BASIS FOR LIGAMENT RECONSTRUCTION IN THE KNEE HAVE HAD A HIGH RATE OF FAILURE AND HAVE NOT MAINTAINED THEIR INTEGRITY OVER TIME AUTOGRAFT VERSUS ALLOGRAFT  COMMON ORTHOPEDIC SURGERIES MUSCLE REPAIR MUSCLE IS RE-OPPOSED, SUTURED, AND IMMOBILIZED IN A SHORTENED POSITION AS HEALING BEGINS TENDON REPAIR TENDON IS SUTURED, THE REPAIRED MUSCLE-TENDON UNIT IS MAINTAINED IN A SHORTENED POSITION, AS W/ A COMPLETE OF A MUSCLE LONGER IMMOBILIZATION PERIOD MAY BE REQUIRED DUE TO THE VASCULAR SUPPLY TO TENDONS IS POOR LIGAMENT REPAIR OR RECONSTRUCTION JOINT IS HELD IN A POSITION THAT PLACES A SAFE LEVEL OF TENSION ON THE SUTURED OR RECONSTRUCTED LIGAMENT DURING THE HEALING PROCESS. IMMOBILIZATION VARIES W/ THE SITE AND SEVERITY OF INJURY AND THE TYPE OF REPAIR OR RECONSTRUCTION THAT WAS DONE. BICEP TENDON REPAIR  COMMON ORTHOPEDIC SURGERIES CAPSULE STABILIZATION AND RECONSTRUCTION DESIGNED TO REDUCE CAPSULAR LAXITY AND JOINT VOLUME AND RESTORE OR IMPROVE JOINT STABILITY FALL INTO SEVERAL CATEGORIES AND ARE PERFORMED USING OPEN OR ARTHROSCOPIC APPROACHES CAPSULORRHAPHY (CAPSULAR SHIFT) - TIGHTENING CAPSULOLABRAL RECONSTRUCTION ELECTROTHERMALLY ASSISTED CAPSULORRHAPHY – SHRINK IDENTIFIED REGIONS OF LAXITY TENDON TRANSFER OR REALIGNMENT THE DISTAL ATTACHMENT OF THE MUSCLE-TENDON UNIT IS REMOVED FROM ITS BONY INSERTION AND REATTACHED TO A DIFFERENT BONE, TO A DIFFERENT LOCATION ON THE SAME BONE, OR TO ADJACENT SOFT TISSUES. MUSCLE-TENDON UNIT IS THEN IMMOBILIZED IN A SHORTENED POSITION FOR A PERIOD OF TIME.  COMMON ORTHOPEDIC SURGERIES RELEASE, LENGTHENING, OR DECOMPRESSION OF SOFT TISSUE USED TO IMPROVE ROM, PREVENT OR MINIMIZE PROGRESSIVE DEFORMITY, OR RELIEVE PAIN MYOTOMY – A PORTION OF THE MUSCLE-TENDON UNIT IS SURGICALLY SECTIONED AND FIBROTIC TISSUES ARE INCISED TENOTOMY – IN A Z-LENGTHENING TO ALLOW GREATER EXTENSIBILITY IMMOBILIZED IN A LENGTHENED POSITION EXCEPT DURING EXERCISE FASCIOTOMY – DECOMPRESSING MUSCLES, TENDONS, OR NERVES MAY BE RELEASED OR REMOVED REMOVAL OSTEOPHYTES OR ALTERATION OF BONY STRUCTURES THAT ARE CONTRIBUTING TO THE EXCESSIVE PRESSURE ON SOFT TISSUE  FASCIOTOMY WARNING THIS IS GRAPHIC! HTTPS://VIMEOPRO.COM/ORTHOTRAUMAASSN/2015-SURGI CAL-TECHNIQUE-VIDEOS/VIDEO/187066285  COMMON ORTHOPEDIC SURGERIES JOINT PROCEDURES ARTHROSCOPIC DEBRIDEMENT AND LAVAGE ARTHROSCOPIC REMOVAL OF FIBRILLATED CARTILAGE, UNSTABLE CHONDRAL FLAPS, AND FRAGMENTS OF CARTILAGE OR BONE FROM A JOINT SYNOVECTOMY REMOVAL OF THE SYNOVIAL LINING OF THE JOINT IN THE PRESENCE OF CHRONIC JOINT INFLAMMATION (RHEUMATOID ARTHRITIS PATIENTS) ARTICULAR CARTILAGE PROCEDURES ABRASION ARTHROPLASTY, SUBCHONDRAL DRILLING, AND MICROFRACTURE USED TO PROMOTED HEALING OF SMALL CHONDRAL DEFECTS IN SYMPTOMATIC JOINTS CHONDROCYTE TRANSPLANTATION DESIGNED TO STIMULATE GROWTH OF HYALINE CARTILAGE FOR REPAIR OF ARTICULAR CARTILAGE FOCAL DEFECTS AND TO PREVENT PROGRESSIVE DETERIORATION OF JOINT CARTILAGE 1ST STAGE = HARVEST AND PROCESSED IN A LAB TO INCREASE A HEALTHY VOLUME OF TISSUE 2ND STAGE = OPEN PROCEDURE, DEBRIDEMENT OF DEFECT SITES, NEW TISSUE INSERTED OSTEOCHONDRAL AUTOGRAFTS OR ALLOGRAFTS TRANSPLANTATION OF INTACT ARTICULAR CARTILAGE ALONG W/ SOME UNDERLYING BONE, RESULTING IN A BONE TO BONE GRAFT  COMMON ORTHOPEDIC SURGERIES JOINT PROCEDURES ARTHROPLASTY DESIGNED TO RELIEVE PAIN AND IMPROVE FUNCTION EXCISION ARTHROPLASTY REMOVE PERIARTICULAR BONE FROM ONE OR BOTH ARTICULAR SURFACES AND FILLED W/ FIBROTIC SCAR TISSUE DURING THE HEALING PROCESS EXCISION ARTHROPLASTY WITH IMPLANT ARTIFICIAL IMPLANT IS INSERTED TO HELP IN THE REMODELING OF A NEW JOINT INTERPOSITION ARTHROPLASTY RESURFACING OF A JOINT TO PROVIDE A NEW ARTICULATING SURFACE JOINT REPLACEMENT ARTHROPLASTY TOTAL JOINT REPLACEMENT IS A COMMON RECONSTRUCTIVE PROCEDURE TO RELIEVE PAIN AND IMPROVE FUNCTION IN PATIENTS W/ SEVERE JOINT DEGENERATION ASSOCIATED W/ LATE-STAGE ARTHRITIS  COMMON ORTHOPEDIC SURGERIES ARTHRODESIS SURGICAL FUSION OF THE JOINT SURFACES IN THE POSITION OF MAXIMUM FUNCTION IS ACHIEVED W/ INTERNAL FIXATION PINS, NAILS, SCREWS, PLATES, AND BONE GRAFTS EXTRA-ARTICULAR BONY PROCEDURES OPEN REDUCTION AND INTERNAL FIXATION OF FRACTURES AFTER EXPOSING THE FRACTURE SITE DURING SURGERY, ANY NUMBER OF INTERNAL FIXATION DEVICES, MAY BE USED TO ALIGN AND STABILIZE THE BONE FRAGMENTS. AFTER THE FRACTURE HAS HEALED, A SECONDARY SURGERY MAY BE NECESSARY TO REMOVE SOME OR ALL OF THE INTERNAL FIXATIONS DEVICES BECAUSE THEY TEND TO MIGRATE OVER TIME. OSTEOTOMY SURGICAL CUTTING AND REALIGNMENT OF BONE EXTRA-ARTICULAR PROCEDURE INDICATED FOR THE MANAGEMENT OF IMPAIRMENTS ASSOCIATED W/ A NUMBER OF MUSCULOSKELETAL DISORDERS.