Knee Replacement (Arthroplasty)

Reasons for knee replacement 1) persistent pain (due to OA), 2) immobility that interferes with daily life.
Joint replacement aims to remove the affected parts of the joint and insert artificial components to stop pain and improve mobility
Inflammation and loss of cartilage cause stiffness, joint deformity, restricted movement
Partial unicompartmental, involving the end of just one bone, either tibia or femur.
Total the ends of both bones (often the patella) are renewed.
Arthroplasty Step by Step
- Use titanium or cobalt/chromium to replace ends of the long bones of the knee
- High-density plastic liner (polyethylene) which sits on the tibia to separate the two
- Held in place by bone cement such as polymethylmethacrylate dries quickly.
o Cemented are quicker healers than screws/bolts
1. Put pt to sleep.
2. Inject leg muscle with relaxant to reduce tension in leg. Place tourniquet to thigh to stop blood flow to knee.
3. Make incision down front of knee from 8-12in. (Quadriceps may need to be cut to allow manipulation of patella).
4. Flex knee to 90
o
. Retractors placed.
5. Remove damaged surface of femur with bone saw. Dont let saw get above 113
o
F (long term damage to bone may occur)/
Holles are drilled into the lower end of the cut femur for placement of new prosthesis.
6. Damaged surface of tibia is removed. Hole drilled down into the top of the prepared tibia to accept peg on the base plate.
7. Resurfacing of patella may be necessary.
8. Temporarily position tibial and femoral components to ensure stability and alignment. Both with knee bent and straight.
9. Refit metal components using bone cement.
10. Let down tourniquet and asses range of motion.
11. Clean joint. Close joint capsule and skin wound repaired with stiches or clips.
12. Drain and dress as necessary.
Knee replacements last about 10-20 years.
Complications include increased risk of blood clots in legs. Reduced by early mobilization, compression stockings, intermittent
compression pump during and after surgery and blood thinning medications.
After knee replacement avoid high-impact exercises such as running and jumping. Walking, swimming, and cycling are ok.
Acute compartment syndrome
- Increased pressure within an osteofascial compartment that can lead to ischemic necrosis.
- Pain, paresthesias, paralysis, pressure, pain on passive movement, pallor (cyanosis)
- Complications necrosis of muscle, nerve damage, contractures, myoglobinuria
- Tx: Bivalve and split casts, removing constricting dressings, place extremity at heart level.
o Perform fasciotomy if pressure >40mmHG within 4 hours if possible
Unhappy triad lateral knee injury resulting in ACL tear, MCL tear and medial meniscus injury!

Hemorrhoidectomy/PPH
Engorgement of the nevous plexi of the rectum, anus or both. With protrusion of the mucosa, anal margin or both.
SSx; anal mass/prolapse, bleeding, itching, pain
External = PAINFUL!
Causes: constipation, straining, portal HTN, pregnancy
Internal/External dentate line (junction of the rectum *columnar epithelium* with the anus *squamous epithelium*)
Locations: Left lateral Right posterior Right anterior
Degree Classification
- First Degree: hemorrhoid that does not prolapse
- Second Degree: hemorrhoid that prolapses with defecation, but returns on its own
- Third Degree: hemorrhoid that prolapses with defecation or any type of Valsalva maneuver and required active manual
reduction (EAT FIBER!)
- Fourth Degree: hemorrhoid that prolapses and cannot be reduced
Treatment
- High fiber diet, anal hygiene, topical steroids, sitz baths
- Rubber band ligation (in most cases anesthetic is not necessary for internal hemorrhoids)
- Surgical resection for large refractory hemorrhoids
Complications
- Exsanguination (bleeding)
- Pelvic infection
- Incontinence sphincter injury
- Anal stricture
Contraindication for hemorrhoidectomy Crohns disease
Must R/O colon cancer

Procedure for Prolapse and Hemorrhoids (PPH) ethicon
- Clinical trial results comparing Procedure for Prolapse and Hemorrhoids to conventional hemorrhoid surgery have shown
that patients who have the PPH procedure may experience:less pain; a quicker recovery period; less overall complications;
need for less postoperative pain medication
- Using a hemorrhoidal circular stapler device, the procedure for prolapse and hemorrhoids procedure essentially "lifts up,"
or repositions the mucosa, or anal canal tissue, and reduces blood flow to the internal hemorrhoids. These internal
hemorrhoids then typically shrink within four to six weeks after the procedure. The PPH procedure results in less pain than
traditional hemorrhoidectomy procedures because it is performed above the area where a person would feel pain, or
dentate line inside the anal canal. The advantage is that this hemorrhoid treatment method affects few nerve endings,
while traditional hemorrhoidectomy procedures are performed below dentate line, affecting many sensitive nerve endings.
- PPH is indicated for patients with
o Second degree hemorrhoids after failure of multiple rubber band ligation
o Third and fourth degree hemorrhoids
o Rectal mucosal prolapse
- PH Hemorrhoid Surgery Risks and Complications
o As with any surgical procedure, there are risks that accompany PPH:
If too much muscle tissue is drawn into the device, it can result in damage to the rectal wall resulting in
inflammation or infection.
The internal muscles of the sphincter may be damaged, resulting in short-term or long-term dysfunction,
such as severe pain or incontinence.

Reduces the prolapse of hemorrhoidal tissue by excising a band of the prolapsed anal mucosa membrane with the use of a circular stapling device. The prolapsed
tissue is pulled into a device that allows the excess tissue to be removed while the remaining hemorrhoidal tissue is stapled. This restores the hemorrhoidal tissue
back to its original anatomical position. The introduction of the Circular Anal Dilator causes the reduction of the prolapse of the anal skin and parts of the anal
mucous membrane. After removing the obturator, the prolapsed mucous membrane falls into the lumen of the dilator. The Purse-String Suture Anoscope is then
introduced through the dilator. This anoscope will push the mucous prolapse back against the rectal wall along a 270 circumference, while the mucous membrane
that protrudes through the anoscope window can be easily contained in a suture that includes only the mucous membrane. By rotating the anoscope, it will be
possible to complete a purse-string suture around the entire anal circumference. The Hemorrhoidal Circular Stapler is opened to its maximum position. Its head is
introduced and positioned proximal to the purse-string, which is then tied with a closing knot. The ends of the suture are knotted externally. Then the entire casing of
the stapling device is introduced into the anal canal. During the introduction, it is advisable to partially tighten the stapler. With moderate traction on the purse-
string, a simple maneuver draws the prolapsed mucous membrane into the casing of the circular stapling device. The instrument is then tightened and fired to staple
the prolapse. Keeping the stapling device in the closed position for approximately 30 seconds before firing and approximately 20 seconds after firing acts as a
tamponade, which may help promote hemostasis. Firing the stapler releases a double staggered row of titanium staples through the tissue. A circular knife excises
the redundant tissue. A circumferential column of mucosa is removed from the upper anal canal. Finally, the staple line is examined using the anoscope. If bleeding
from the staple line occurs, additional absorbable sutures may be placed.

Herniorrhaphy, Ventral with Mesh
Ventral hernias occur in the midline along the linea alba, usually between the xiphoid and umbilicus
- Incisional hernia weakness or defect in the abdominal wall that occurs at a site of prior surgical incision
o MC type of ventral hernias! 5% of abdominal surgeries end with ventral hernias
o RF inadequate fascial closure, wound infection, midline incision, obesity, preggo, ascities, malnutrition, elderly,
peritoneal dialysis, steroids and chemotherapy
- Epigastric hernia herniation through a defect in the linea alba above the umbilicus
o MC in men, may be multiple

Ventral Hernia Repair (Laparoscopic)
Certain risk factors predispose patients to develop incisional hernias, such as obesity,
diabetes, respiratory insufficiency (lung disease), steroids, wound contamination,
postoperative wound infection, smoking, inherited disorders such as Marfan's
syndrome and Ehlers-Danlos syndrome, as well as poor surgical technique.

The principle of surgical repair entails the use of prosthetic mesh to repair large
defects in order to minimize tension on the repair. A tension free repair has a lesser
chance of hernia recurrence. Traditionally, the old scar is incised and removed, and
the entire length of the incision inspected. Generally, there are multiple hernia
defects other than the one(s) discovered by physical examination. The area requiring
coverage is usually large and requires much surgical dissection. A prosthetic mesh is
used to cover the defect(s), and the wound closed. This is a major surgical procedure
and often complicated. Infection rates following repair may be as high a 7.0%.
Recurrence can be up to 5%, or higher, depending on the patient's preoperative risk
factors. While the use of prosthetic mesh has decreased the number of recurrences,
it has also been implicated in increased infection rates, adhesion or scar formation
of the abdominal contents to the anterior abdominal wall leading to intestinal
obstruction and fistula formation. However, overall, recovery is usually excellent and
patients return to normal activity within a matter of weeks.

The laparoscopic repair of ventral hernias was designed to minimize operative trauma to the patient. As mentioned, these are often
complicated repairs requiring large incisions and extensive tissue dissection. The principles governing a laparoscopic ventral hernia
repair are based on those of open Stoppa ventral hernia repair. A large piece of prosthetic mesh is placed under the hernia defect
with a wide margin of mesh outside the defect (see figure). The mesh is anchored in to place with eight full thickness sutures and
secured to the anterior abdominal wall with a varying number of tacs, placed laparoscopically.

A patient is a candidate for laparoscopic incisional hernia repair if they are medically able to undergo general anesthesia. Also, the
defect must "allow" the surgeon to place the laparoscopic trocars in such positions that repair are ergonomically possible. In some
very large or giant hernias, the abdominal wall is distorted to such a degree that it is impossible to safely place laparoscopic trocars.
Ancillary studies, such as CT scan of the abdomen and pelvis are helpful in making this decision. Patients are also given a bowel
preparation to evacuate the colon and decrease the number of intestinal bacteria prior to surgery.

Patients are admitted the same day of their surgery. Following the procedure and recovery from anesthesia, they are taken to a
hospital room where they spend the night. We encourage our patients to move as quickly as possible. It is extremely important to be
active early in order to stave off some of the complication seen postoperatively, such as pneumonia, deep venous thrombosis and
pulmonary embolism (clots in the legs that break off and go the lungs). Postoperative pain is variable, and can be considerable
during the first 24 hours. As such, patients are given I.V. narcotics as needed, and are changed to oral analgesics the next day.
Generally, most patients stay in the hospital 1 or 3 days following surgery. Patients are then seen, by the surgeon, one to two weeks
after discharge. There is no dietary restriction. Activity level is restricted by the patient's comfort level. However, it is generally not
advisable to engage in any strenuous exercise or heavy lifting for several weeks, to allow the hernia repair to heal.