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 OPERATIVE
ORTHOPAEDICS
 OPERATIVE
ORTHOPAEDICS
THE STANMORE GUIDE
SECOND EDITION

Edited by

Timothy WR Briggs MD MBBS (Hons), MCH

(Orth), FRCS (Eng), FRCS (Ed), MD (Res)
Royal National Orthopaedic Hospital Trust, Stanmore, UK

Jonathan Miles MBChB, FRCS (Tr & Orth)

Royal National Orthopaedic Hospital Trust, Stanmore, UK

William Aston BSc, MBBS, FRCS (Tr & Orth) (Edinb)

Royal National Orthopaedic Hospital Trust, Stanmore, UK

Heledd Havard BSc, MBBCh, MSc, FRCS (Tr & Orth)

Royal National Orthopaedic Hospital Trust, Stanmore, UK

Daud TS Chou MBBS, BSc, MSc, FRCS (Tr & Orth)

Cambridge University Hospitals NHS Foundation Trust
Cambridge, UK
Second edition published 2020
by CRC Press
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© 2021 Taylor & Francis Group, LLC

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 Contents
Preface...........................................................vii 10 Surgery of the Hip...............................239
Acknowledgements........................................ix Daud TS Chou, Jonathan Miles and
Contributors....................................................xi John Skinner

1 Anaesthesia in Orthopaedic Surgery......1 11 Surgery of the Knee............................279

James Cremin and Michael Cooper Alexander D Liddle, Lee A David
and Timothy WR Briggs
2 Tumours..................................................11
12 Soft Tissue Surgery of the Knee........321
Heledd Havard, William Aston and
Timothy WR Briggs Stephen Key, Jonathan Miles and Richard
Carrington
3 Surgery of the Cervical Spine...............25
13 Surgery of the Ankle...........................367
Julian Leong and Kia Rezajooi
Matthew Welck, Laurence James and
4 Surgery of the Thoracolumbar Dishan Singh
Spine........................................................43
14 Surgery of the Foot.............................385
Daniel P Ahern, Joseph S Butler,
Matthew Shaw and Sean Molloy Yaser Ghani, Simon Clint and
Nicholas Cullen
5 Surgery of the Peripheral Nerve..........63
15 Limb Reconstruction...........................427
Ravikiran Shenoy, Gorav Datta,
Max Horowitz and Mike Fox Robert Jennings and Peter Calder

6 Surgery of the Shoulder........................85 16 Paediatric Orthopaedic Surgery........443

Nick Aresti, Omar Haddo and Jonathan Wright, Russell Hawkins,
Mark Falworth Aresh Hashemi-Nejad and Peter Calder

7 Surgery of the Elbow..........................113 17 Amputations........................................483

Alan Salih, David Butt and Heledd Havard, William Aston and
Deborah Higgs Rob Pollock
Index............................................................495
8 Surgery of the Wrist...........................159
Ramon Tahmassebi, Sirat Khan and
Kalpesh R Vaghela

9 Surgery of the Hand............................193

Norbert Kang, Ben Miranda and
Dariush Nikkhah

v
 Preface
Orthopaedic training and surgical practice
have seen significant developments over
recent decades and continue to represent
some of the most exciting surgical sub-
specialities. While the original concept of
this book was none other than a ‘professorial
moment … in the bath’, editing the recent
edition has been somewhat of a marathon
over the past three years. This text is not
intended to serve as a complete guide to
elective orthopaedics; it is designed to
illustrate the basic principles and surgical
techniques of common orthopaedic
procedures, providing the reader with a solid
overview presented in a systematic format.
High-pressure environments are somewhat
commonplace in the life of the orthopaedic
trainee, not least during preparation for the
Fellowship of the Royal College of Surgeons
(FRCS) examination – thus the format of this
text is set to be utilised both as a learning
model and also in structuring answers.
Procedures are described in a concise and
consistent format to enable the reader to
describe and carry out safe, evidence-
based approaches while reinforcing the
fundamentals of basic principles.
While this text offers a general overview
of common procedures and techniques, it
certainly should not be used as a substitute
for the detailed knowledge required of
the senior trainee approaching the exam.
Under stressful conditions trainees can
find themselves fumbling over answers,
and developing strategies to structure
answers succinctly is an investment worth
making. As in the world of rugby, ‘the more
you sweat in training, the less you bleed in
battle’, and in the words of Albert Einstein,
‘If you can’t explain it simply, you don’t
understand it well enough’.
To all future trainees, I hope that this
book serves as a general guide with
solid principles presented in a readable
format and will act as a stepping stone in
your learning and understanding of the
curriculum.
vii
 Acknowledgements
1 Anaesthesia in Orthopaedic Surgery
contains some material from Anaesthesia
in Orthopaedic Surgery by Hui Yin Vivian
Ip and Michael Cooper. The material has
been revised and updated by the current
authors.
3 Surgery of the Cervical Spine contains
some material from Surgery of the Cervical
Spine by Raman Kalyan and David Harrison.
The material has been revised and updated
by the current authors.
7 Surgery of the Elbow contains some
material from Surgery of the Elbow by
Simon Lambert. The material has been
revised and updated by the current
authors.
8 Surgery of the Wrist contains some
material from Surgery of the Wrist by
James Donaldson and Nicholas Goddard.
The material has been revised and updated
by the current authors.
9 Surgery of the Hand contains some
material from Surgery of the Hand by
Robert Pearl and Lauren Ovens. The
material has been revised and updated by
the current authors.
ix
 Contributors
Daniel P Ahern Simon Clint Omar Haddo
Centre for Biomedical Royal National Orthopaedic Whittington Hospital
Engineering Hospital Trust London, United Kingdom
Trinity College Stanmore, United Kingdom
Dublin, Ireland Aresh Hashemi-Nejad
Michael Cooper Royal National Orthopaedic
Nick Aresti Department of Anaesthetics Hospital Trust
Barts Health NHS Trust Royal National Orthopaedic Stanmore, United Kingdom
London, United Kingdom Hospital Trust
Stanmore, United Kingdom and
William Aston
James Cremin
Royal National Orthopaedic University College London
Department of Anaesthetics
Hospital Trust London, United Kingdom
Royal National Orthopaedic
Stanmore, United Kingdom
Hospital Trust
Heledd Havard
Timothy WR Briggs Stanmore, United Kingdom
Royal National Orthopaedic
Royal National Orthopaedic Nicholas Cullen Hospital Trust
Hospital Trust Royal National Orthopaedic Stanmore, United Kingdom
Stanmore, United Kingdom Hospital Trust
Stanmore, United Kingdom Russell Hawkins
Joseph S Butler
Royal National Orthopaedic
Mater Private Hospital Gorav Datta Hospital Trust
Dublin, Ireland Royal National Orthopaedic Stanmore, United Kingdom
Hospital Trust
David Butt Stanmore, United Kingdom Deborah Higgs
Royal National Orthopaedic
Lee A David Royal National Orthopaedic
Hospital Trust
Maidstone and Tunbridge Hospital Trust
Stanmore, United Kingdom
Wells NHS Trust Stanmore, United Kingdom
Peter Calder Maidstone, United Kingdom
Royal National Orthopaedic Max Horowitz
Mark Falworth Royal National Orthopaedic
Hospital Trust
Royal National Orthopaedic Hospital Trust
Stanmore, United Kingdom
Hospital Trust Stanmore, United Kingdom
Richard Carrington Stanmore, United Kingdom
Royal National Orthopaedic Laurence James
Mike Fox
Hospital Trust Royal National Orthopaedic
Royal National Orthopaedic
Stanmore, United Kingdom Hospital Trust
Hospital Trust
Stanmore, United Kingdom
Stanmore, United Kingdom
Daud TS Chou
Cambridge University Yaser Ghani Robert Jennings
Hospitals NHS Foundation Royal National Orthopaedic Royal National Orthopaedic
Trust Hospital Trust Hospital Trust
Cambridge, United Kingdom Stanmore, United Kingdom Stanmore, United Kingdom

xi
xii Contributors
Norbert Kang
Royal Free Hospital
London, United Kingdom
Stephen Key
Royal National Orthopaedic
Hospital Trust
Stanmore, United Kingdom
Sirat Khan
Royal Free London NHS
Foundation Trust
Stanmore, United Kingdom
Julian Leong
Royal National Orthopaedic
Hospital Trust
Stanmore, United Kingdom
Alexander D Liddle
Division of Surgery
Imperial College
and
Imperial College Healthcare
NHS Trust
London, United Kingdom
Jonathan Miles
Royal National Orthopaedic
Hospital Trust
Stanmore, United Kingdom
Ben Miranda
Andrew’s Centre for Plastic
Surgery and Burns
Essex, United Kingdom
Sean Molloy Dishan Singh
Royal National Orthopaedic Royal National Orthopaedic
Hospital Trust Hospital Trust
Stanmore, United Kingdom Stanmore, United Kingdom
Dariush Nikkhah John Skinner
Department of Plastic and Royal National Orthopaedic
Reconstructive Surgery Hospital Trust
Royal Free London NHS Stanmore, United Kingdom
Foundation Trust
Ramon Tahmassebi
Stanmore, United Kingdom
King’s College Hospital
Rob Pollock London, United Kingdom
Royal National Orthopaedic
Kalpesh R Vaghela
Hospital Trust
Trauma and Orthopaedic
Stanmore, United Kingdom
Registrar
Kia Rezajooi Royal National Orthopaedic
Royal National Orthopaedic Hospital
Hospital Trust Percivall Pott Rotation
Stanmore, United Kingdom London, United Kingdom
Alan Salih Matthew Welck
School of Medicine Royal National Orthopaedic
King’s College London Hospital Trust
London, United Kingdom Stanmore, United Kingdom
Matthew Shaw Jonathan Wright
Royal National Orthopaedic Royal London Hospital
Hospital Trust Barts and London NHS Trust
Stanmore, United Kingdom London, United Kingdom
Ravikiran Shenoy
Royal Free London NHS
Foundation Trust
Stanmore, United Kingdom
1 Anaesthesia in
Orthopaedic Surgery
James Cremin and Michael Cooper

Introduction 1 Postoperative care 6

Preoperative assessment 1 Viva questions 9
Intraoperative techniques 5

Introduction
The orthopaedic patient population presents many challenges. It includes the extremes
of age, comes with a range of embedded medical co-morbidities and presents with
diverse surgical pathology requiring varied intervention. Procedures range from day-
case minimally invasive arthroscopic procedures to extensive operations that test
the physiological reserve of an individual patient. Due to these concerns, an individual
anaesthetic is customised to the medical demands of the patient, the requirements
for the surgical technique and the limitations of the institution in which the surgery
occurs.

Preoperative assessment
This is the process of assessing the relevance, severity and treatment of medical
pathologies. This allows referral for better treatment (‘optimisation’) and quantification of
the risk of adverse perioperative events, including death, to be discussed and documented.
Factors specific to anaesthesia, such as a possible difficult airway, may also be considered.
Guidelines exist to inform the ordering of preoperative laboratory tests. In addition, the
optimisation of patients prior to admission for surgery is aimed to reduce cancellations on
the day of surgery and to increase the productivity of the theatre suite.

Fasting
In elective surgery, standard local fasting times must be adhered to. A typical regimen is
given in Table 1.1. Food includes milk and fresh fruit juices. It is safe for patients (including
diabetics) to drink specialised carbohydrate-rich (maltodextrins) drinks up to 2 hours
before elective surgery as this improves subjective well-being, reduces thirst and hunger
and reduces postoperative insulin resistance.
2 1 Anaesthesia in Orthopaedic Surgery

Table 1.1 Fasting times

Typical foods
Solid food Water Breast milk Formula milk
Fasting time 6 hours 2 hours 4 hours 6 hours

In trauma situations, gastric emptying is affected from the time of injury and is further
complicated by the use of opiate analgesics that prolong gastric emptying. Fasting times
are difficult to interpret in this situation but can be calculated as the time of intake to
time of trauma. In certain situations, the clinical priority for surgical intervention may
override fasting policy, and clear discussion between clinicians caring for the patient
needs to occur.

Airway
Airway assessment involves both bedside tests and if needed, radiological tests. A range of
bedside tests exist that aim to predict difficulties in maintaining an airway or intubating
an anaesthetized patient. Used individually, each airway assessment has poor sensitivity
and specificity, however when combined can be a useful marker.
Of particular importance in orthopaedic surgery is pathology or trauma to the cervical
column. Rigidity of the cervical column (e.g. in ankylosing spondylosis) may cause a
problem with maintaining an airway and with difficult laryngoscopy. An unstable cervical
column (e.g. trauma or rheumatoid arthritis) can lead to cord injury. Initial radiological
assessment is with a plain film in anteroposterior (AP), lateral, flexion and extension views.
If there are any concerns, then specialised investigations to delineate pathology include
computed tomography (CT) and magnetic resonance imaging (MRI).

Cardiovascular assessment
Cardiovascular assessment is aimed at quantifying the ability of the cardiovascular
pump to increase work to match perioperative metabolic demands. This is during both
the operative period and rehabilitation. It is an assessment of reserve and a prediction of
adverse events such as an acute coronary syndrome. Key clinical markers are described in
the following sections.

Exercise tolerance/functional status

For patients having major, non-cardiac surgery, the inability to climb two flights of stairs
confers an increased risk of major postoperative complications but is not predictive of
mortality. Difficulties in this assessment are common for orthopaedic patients due to their
pathology affecting mobility.

Previous myocardial infarction

There is a risk of recurrent perioperative myocardial infarction (MI), which has a 60%
mortality rate. The longer surgery can be postponed after an MI, the lower is the rate of
recurrent MI (Table 1.2).
 Preoperative assessment 3

Table 1.2 Percentage risk of recurrent myocardial infarction

(MI) at different times after MI

Time since MI Risk of recurrent MI (%)

<3 months 5.7

4–6 months 2.3
>6 months 1.5

Investigations
Typical investigations used to quantify cardiac reserve are as follows:

• Exercise electrocardiogram (ECG): This helps to determine any coronary flow limitation
when cardiac work increases.
• 24-hour ECG recording (Holter monitor): This involves continuous ECG recording for
24–48 hours to investigate possible arrhythmia.
• Thallium scintigraphy and dobutamine stress echocardiography: These dynamic ‘stress
tests’ are especially useful for patients who are unable to perform exercise ECG due to
musculoskeletal disease or severe cardiopulmonary disease. Perfusion defects of the
myocardium under physiological stress indicate coronary insufficiency.
• Cardiovascular MRI: This is a non-invasive assessment of the function and structure
of the cardiovascular system. It provides information on cardiac structure,
cardiomyopathy and perfusion defects.
• Cardiopulmonary exercise testing: This is a dynamic test that predicts the patient’s
anaerobic threshold. It can indicate the respiratory and cardiac reserve but can be
affected by other factors such as motivation, mobility and nutrition. It can be used to
predict the risk of surgery and obviate the need for other tests such as angiography or
echocardiography.
• Coronary angiography: This is used to visualize coronary arterial flow and disease. This
is often the end point of coronary investigation and may allow treatment by stenting
and angioplasty at the same time.

Hypertension
Hypertensive patients are at a higher risk of labile blood pressures intraoperatively
compared to the non-hypertensive population. Blood pressure management is aimed to
reduce cardiovascular morbidity over years and decades, but there is no evidence that
perioperative blood pressure reduction affects cardiovascular risk.
For elective surgery, if mean blood pressures in primary care in the past 12 months are less
than 160 mm Hg systolic and less than 100 mm Hg diastolic (160/100 mm Hg), surgery can
proceed.
If there is no evidence of normotension in primary care, then elective surgery should
proceed for patients if their blood pressure is less than 180 mm Hg systolic and 110 mm Hg
diastolic (180/110 mm Hg) when measured in the hospital setting.
4 1 Anaesthesia in Orthopaedic Surgery

Heart murmurs
The valve pathology underlying murmurs may have significant implications for anaesthetic
technique. Lesions that limit the cardiac output (particularly aortic stenosis) can cause
profound hypotension as the heart cannot increase cardiac output to maintain blood
pressure as peripheral vascular resistance drops. This is most marked with neuraxial
anaesthesia and can cause morbidity due to organ hypo-perfusion. For example,
coronary perfusion may become critically low resulting in an acute coronary syndrome.
Echocardiography is useful to determine the nature and the severity of the valve lesion.

Respiratory assessment
Preoperative assessment determines the severity and potential reversibility of respiratory
pathology. Disease states limit gas flow, gas exchange or both. The end point of respiratory
disease is hypoxaemia and tissue hypoxia. This can precipitate organ failure with serious
adverse outcomes. Common pathologies are described in the following sections.

Asthma
Stable asthma is usually benign, but some anaesthetic agents can trigger bronchospasm
and are avoided. Conversely, some anaesthetic agents can result in bronchodilation
and are favoured. Assessment should include spirometry and peak flow measurements.
Preparation may include bronchodilator premedication, e.g. salbutamol, and some
anaesthetists prefer a regional technique to avoid airway instrumentation and opiate use.
Elective surgery should not proceed with concurrent upper respiratory tract infection.

Chronic obstructive airways disease

Gas flow and exchange are limited in this disease. These patients are at risk of postoperative
respiratory failure due to atelectasis and segmental lung collapse causing hypoxaemia.
Assessment includes spirometry (a forced expiratory volume in 1 second greater than 1 L
indicates an ability to clear secretions), oximetry (and perhaps arterial blood gas sampling)
and an assessment of exercise ability. A baseline chest radiograph may be useful but is by no
means mandatory. An ECG may show signs of right heart strain and is also indicated as this
group is likely to have co-existent cardiovascular disease. Preoperative and postoperative
chest physiotherapy are essential. Anaesthetists will tend towards regional anaesthesia
in patients with significant disease burden to minimise the chances of postoperative
respiratory failure. Opiates are a potent source of respiratory depression and, coupled to
sedation and pain, can be a powerful trigger for respiratory decompensation.

Respiratory tract infection

Respiratory tract infections are often viral, and the most common are located in the upper
respiratory tract. Patients with a productive cough or objective symptoms of pyrexia,
fatigue, myalgia and/or anorexia should only proceed if emergency surgery is indicated.
The risk of laryngospasm and bronchospasm is increased. Viral myocarditis may also
occur, leading to cardiac failure or even death in the perioperative period. Guidelines
advise a 4- to 6-week delay for elective surgery.
 Intraoperative techniques 5

Groups at special risk

Patients with cerebral palsy may have poor bulbar function and weak cough, which
puts them at risk of aspiration, and they have a higher incidence of postoperative
respiratory tract infection. This is exacerbated by any cognitive impairment that
reduces their ability to cooperate with physiotherapy and interventions such as non-
invasive ventilation. Patients with low-tone neuromuscular syndrome are at risk
of postoperative respiratory failure, and plans will include intensive care, possible
postoperative ventilation and tracheostomy requirement. Of note, volatile anaesthesia
is usually avoided in this group due to the risk of rhabdomyolysis, renal failure and
hyperkalaemic cardiac arrest.

Recommended references
Fischer HBJ, Simanski CJP. A procedure specific and systematic review and consensus recommendations
for analgesia after total hip replacement. Anaesthesia. 2005;60:1189–1202.
Fischer HBJ, Simanski CJP, Sharp C et al. A procedure specific systematic review and consensus
recommendations for postoperative analgesia following total knee arthroplasty. Anaesthesia.
2008;63:1105–1123.
Fowler SJ, Symons J, Sabato S et al. Epidural analgesia compared with peripheral nerve blockade after
major knee surgery: A systematic review and meta-analysis of randomized trials. Br J Anaesth.
2008;100:154–164.
Goodnough LT, Shander A. Patient blood management. Anesthesiology. 2012;116(6):1367–1376.
Muñoz M, Acheson AG, Auerbach M et al. International consensus statement on the peri-operative
management of anaemia and iron deficiency. Anaesthesia. 2017;72:233–247.
Simpson JC, Moonesinghe SR, Grocott MP et al. Enhanced recovery from surgery in the UK: An audit of
the enhanced recovery partnership programme 2009–2012. Br J Anaesth. 2015;115(4):560–568.

Intraoperative techniques
Discussion of the selection and conduct of individual techniques is beyond the scope of
this chapter. The technique chosen is multifactorial and is dependent upon the patient,
hospital, procedure, surgeon and anaesthetist. There is little conformity of opinion.

General anaesthesia
This is the most common option and is entirely appropriate for most procedures, environ­
ments and patients. It is a balanced technique of analgesia, muscle relaxation and sedation.
This is confirmed by data review as exemplified by recent publications concerning primary
joint replacement.

Peripheral regional anaesthesia

This is the placement of local anaesthetic adjacent to individual nerves or plexus of nerves
to produce a zone of sensory and motor block. This may be the only mode of anaesthesia.
More commonly, it is a pain-relieving adjunct to general anaesthesia or sedation. The
main benefit is to reduce opiate requirement to aid earlier mobilisation but neurological
injury may be masked. A prolonged motor block may occur which is to the detriment
of the patient. Increasingly this modality is preferred for primary arthroplasty but is
increasing into other areas.
6 1 Anaesthesia in Orthopaedic Surgery

Neuroaxial local anaesthesia

For lower limb procedures, spinal, epidural or a combined spinal-epidural block can
provide complete analgesia and motor block. As with previous techniques, they may
be used alone or in combination with sedation or general anaesthesia. They are often
the technique of choice in those with severe respiratory disease burden to reduce the
respiratory complications associated with opiate use. Outcome evidence is poor but there
is some literature base to support this practice. In addition historical data suggest a lower
incidence of deep vein thrombosis and perioperative blood loss. This may no longer be
valid in light of new advances in perioperative care and enhanced recovery programmes.
These techniques remain an important part of a multimodal approach to fast-track surgery.

Contraindications
Patient refusal.
Local or systemic infection.
Allergy to agents used.
Coagulopathy.
Anticoagulants (relative contraindication) increase the risk of haematoma at the site of
infiltration, around nerves or in the epidural space.
Aspirin is not a contraindication.
Chronic neurological diseases (relative contraindication).

Local Anaesthesia
Some body surface procedures are amenable to surgery using local infiltration alone.
Maximal dosages and drug information are given in Table 1.3.

Postoperative care
Analgesia
The “analgesic ladder” was originally published in 1986 by the World Health Organization
(WHO) as a guideline for the use of drugs in the management of pain. Initially intended for
the management of cancer pain, it has evolved to be more widely used for the management
of all types of pain. The general principle is to start with simple analgesics and to escalate
to strong opioids as required. It is advised that medications should be given at regular

Table 1.3 Local anaesthetic drug information

Maximum dose Relative Onset Duration

Drug (mg/kg) Potency (minutes) (hours)
Lidocaine 3 2 5–10 1–2
Lidocaine with adrenaline (1:200 000) 7 2 5–10 2–4
Bupivicaine 2 8 10–15 3–12
Ropivicaine 3 6 10–15 3–12
Prilocaine 6 2 5–10 1–4
 Postoperative care 7

intervals so that continuous pain relief occurs, and dosing be directed by relief of pain
rather than by fixed dosing guidelines.

Simple analgesics
These can be very effective for mild and moderate pain. Common drugs are paracetamol
and non-steroidal anti-inflammatory drugs. Best effect is gained when they are given
regularly, ideally after a loading dose in theatre. In more severe pain, they are still useful
adjuncts with well-documented opiate-sparing properties. Increasing evidence points to
using NSAIDs with care in patients with cardiovascular disease.

Oral opiates
Oral opiates include codeine derivatives, complex agonists such as tramadol and morphine
derivatives. These are well recognised for more severe pain and can be used regularly,
with stronger alternatives available for breakthrough pain. Newer formulations provide
excellent pharmacokinetics with twice daily dosing of modified-release compounds, each
providing 12-hour analgesia. These modified-release tablets are supplemented by short-
acting versions to treat breakthrough pain.

Intravenous opiates
For severe pain, intravenous opiates may be given as patient-controlled analgesia (PCA). This
allows the patient to titrate their own dosing. It is effective, safe and popular. Better pain
scores and fewer side effects (nausea, vomiting and sedation) are regularly achieved using
this modality of opiate delivery compared with intermittent intramuscular dosing. Once the
acute postoperative period has passed, the patient may be stepped down to oral alternatives.

Alternatives
Other routes such as transdermal delivery are available. These take a long time to reach a
steady plasma concentration and are similarly slow to decline when discontinued. They
are more suited to long- term use in chronic pain syndromes. This inflexibility makes them
difficult to use in the perioperative period but consideration should be made preoperatively
to existing analgesic requirements.

Local anaesthesia
Local anaesthetic techniques may be continued into the postoperative period. These
provide excellent analgesia with minimal side effects. However, immobility may be a
problem. In units where utilising local anaesthetic blocks is embedded in practice, they
are very successful and do not need to delay mobilisation.

Oxygen
Oxygen therapy should be given to patients with an epidural infusion which contains opiates,
or those using a PCA. This supplemental oxygen maintains alveolar oxygen tension longer
if respiratory depression and hypoventilation occur. Supplemental oxygen used for the first
three days postoperatively can also minimise the risk of perioperative ischaemic events.
8 1 Anaesthesia in Orthopaedic Surgery

Any patient with pre-existing respiratory pathology or acquired (respiratory tract infection,
atelectasis, thromboembolism) will be relatively hypoxic, and oxygen therapy is essential.

Fluid management
The goal of intravenous fluid therapy is to maintain normovolaemia. This allows adequate
cardiac output and, assuming an appropriate haemoglobin concentration, tissue oxygen
delivery. Maintenance water and electrolytes need to be supplied and ongoing blood loss
compensated for in the form of blood substitute, or blood itself. Patient blood management
has recently been advocated for the perisurgical period to enable treating physicians to
have the time and tools to provide patient-centered evidenced-based care to minimise
allogeneic blood transfusions. It aims to optimise erythropoiesis, minimise blood loss and
manage anaemia.
Triggers for transfusion vary. Blood is expensive, immunosuppressant, associated with
worse outcome and a vehicle for disease transmission. However, red cells are vital to
oxygen delivery and haemostasis. The trigger will depend on the predicted continuing
blood loss, the patient’s co-morbidities and symptoms. This haemoglobin concentration
trigger can be as low as 7 g/dL.

Disposal
High-dependency care may benefit many orthopaedic patients. Delivery of this will depend on
local protocol and infrastructure. Clearly, those at increased risk of organ failure or requiring
a higher level of nursing supervision should be placed in an appropriate environment.

Enhanced recovery
Enhanced recovery is the delivery of a consistent, protocolised pathway of care with the
aim to minimise perioperative stress and to expedite recovery. The amount of evidence
for each individual element of the enhanced recovery bundle is variable. However,
good compliance with enhanced recovery protocols (≥80% compliance) is associated
with a shorter median length of stay by one day in orthopaedic surgery. In particular,
individualised fluid therapy and early mobilisation were the strongest indicators. This
reduction in length of stay represents a clinically important reduction in morbidity and
significant cost savings.

Recommended references
Association of Anaesthetists of Great Britain and Ireland. The measurement of adult blood pressure and
management of hypertension before elective surgery 2016. Anaesthesia. 2016;71:326–337.
Biccard BM. Relationship between the inability to climb two flights of stairs and outcome after major non-
cardiac surgery: Implications for the pre-operative assessment of functional capacity. Anaesthesia.
2005;6:588–593.
Howell S, Sear J, Foex P. Hypertension, hypertensive heart disease and perioperative cardiac risk.
Br J Anaesth. 2004;92:570–583.
National Institute for Health and Care Excellence. April 2016. Routine preoperative tests for elective
surgery. NICE guideline [NG45]. Accessed April 2017. https://www.nice.org.uk/guidance/ng45
 Postoperative care 9

Viva questions
1. In patients with hypertension, how would you determine whether elective surgery can
proceed?
2. What are the contraindications to neuraxial blockade?
3. Why is a respiratory tract infection a problem?
4. Who should receive oxygen therapy in the postoperative period?
5. What are the postoperative options for analgesia for a primary arthroplasty?
2 Tumours
Heledd Havard, William Aston and Timothy WR Briggs

Principles of biopsy 11 Bone cyst curettage with or without

Needle biopsy of bone 11 bone graft 17

Open biopsy of bone 14 Malignant tumour principles 20

Excision of benign bone tumour 16 Viva questions 22

Sarcomas can broadly be classified into benign or malignant tumours and can be either of
soft tissues or of bone. All tumours should be managed via a multidisciplinary team (MDT)
approach at an appropriate dedicated tumour unit consisting of specialised oncology
surgeons, radiologists, histopathologists, paediatricians and oncologists. Appropriate
early referral to a sarcoma unit with careful diagnosis and coordinated management play
a fundamental role in achieving the most successful outcome. Careful discussion and
planning from time of initial presentation through to postoperative care and surveillance
are critical.

Principles of biopsy
All patients presenting with a suspected sarcoma or isolated metastasis should be
referred and discussed at a sarcoma MDT. Once appropriate staging investigations have
been performed, a tissue diagnosis is required to gain a histological diagnosis and plan
subsequent treatment. The biopsy is planned as part of the MDT between the oncology
surgeon and the interventional radiologist.

1. Performed at a specialised sarcoma centre with appropriate histopathology support

2. Planned in accordance with the operating oncology surgeon
3. Includes representative tissue – often from the periphery of the lesion or a membrane
as the central part is often necrotic and non-diagnostic
4. Should not violate any surrounding compartments
5. Biopsy tract should be marked by tattoo to aid excision at time of definitive surgery

Needle biopsy of bone

Preoperative planning
Indications
To obtain a histological diagnosis so that further treatment can be planned.
12 2 Tumours

Contraindications
Lesions that are closely related to neurovascular structures, where a needle biopsy would
put these structures at risk.
Patients should also be warned that a second needle biopsy or open biopsy may be
necessary if an inadequate tissue specimen for histological diagnosis is obtained.

Consent and risks

• Neurovascular injury and infection are the main risks
• Possible tumour seeding

Templating
The needle entry point and tract need careful thought and should be planned by the
surgeon performing the tumour resection, as the biopsy tract will need to be excised if
malignancy is found.

Fine needle aspiration (FNA) is not used in sarcoma diagnosis and is largely reserved to
diagnosing carcinoma. A thicker-bore needle (11G or 13G), capable of boring through the
outside of the lesion and taking core biopsies such as a Jamshidi needle (Figure 2.1), is
preferable.

For tumours that have a large soft tissue component or that have destroyed the cortex,
a Tru-Cut or Temno (preloaded) needle can be used. These take a slice of tissue and
come in 11 and 14 gauges. If there is doubt that the tissue obtained at biopsy may not be
representative, a smear and/or frozen section can be performed by the histopathologist
which may also provide a provisional diagnosis.

Anaesthesia and positioning

Needle biopsy can be done under local, local with sedation or general anaesthesia. For
children, hard lesions and lesions that may be difficult to access, a general anaesthetic
should be used.

Positioning is dependent on the area to be reached and if necessary the imaging modality
being used.

Surgical technique
Landmarks and incision
The line of the biopsy should be sited in the line of a possible future surgical incision, so that it
can be excised at the time of surgery (Figure 2.2). It must pass directly to the site of the tumour
 Needle biopsy of bone 13

Figure 2.1 Jamshidi needle.

and through only the myofascial compartment in which the tumour is located, preferably
through muscle and away from the neurovascular structures at risk. It should aim to take
a representative sample of the tumour, which can be identified on pre-biopsy imaging. The
needle is passed after a simple stab incision in the skin with a number 15 blade.

Deep dissection
The needle is passed through the stab incision directly into the area being biopsied, under
radiological control.

Technical aspects of procedure

Multiple core biopsies are needed, aiming to minimise diversion from the tract. In cases
where preoperative imaging is atypical or where infection is suspected, samples should
also be sent for microbiology.
The needle should not be passed through the lesion into normal tissue. For lesions close to
joints, the needle must not pass through the capsule and therefore potentially contaminate
the joint. It may be necessary to drill the bone prior to needle insertion in sclerotic lesions.
Careful handling of the specimens is important so as not to destroy the microarchitecture.
Discussion with the histopathologist will elucidate whether they wish to receive the
specimen fresh or fixed in formalin.
14 2 Tumours

Deltopectoral
Biopsy
approach

Figure 2.2 Position of biopsy for proximal humeral tumour – in the line of the deltopectoral approach,
but slightly lateral so that the needle passes through the deltoid muscle and avoids the cephalic vein.

Closure
Use Steri-Strips.

Postoperative instructions
• Neurovascular and routine observations.
• Local pressure in the case of vascular lesions.

Recommended references
Saifuddin A, Mitchell R, Burnett S et al. Ultrasound guided needle biopsy of primary bone tumours.
J Bone Joint Surg Br. 2000;82:50–54.
Stoker DJ, Cobb JP, Pringle JAS. Needle biopsy of musculoskeletal lesions. A review of 208 procedures.
J Bone Joint Surg Br. 1991;37:498–500.

Open biopsy of bone

Preoperative planning
Indications
• Patients who are not suitable for a needle biopsy.
• Patients in whom tissue from a needle biopsy was insufficient to make the diagnosis.

Open biopsy can be incisional where a sample of the lesion is taken or it can be excisional
where the whole lesion is removed. Excisional biopsy is generally reserved for lesions
which, on radiology, have diagnostic features of a benign lesion.
 Open biopsy of bone 15

Contraindications
Lesions where a satisfactory needle biopsy can be performed.

Consent and risks

• Neurovascular injury
• Infection
• Seeding of the tumour
• Unexpected histological result with need for further surgery

Templating
The incision should be planned with the surgeon and be made in the line of the surgical
approach that will be used to remove the tumour.
Thought should be given as to how to localise the tumour, e.g. with image intensifier
intraoperatively if necessary.

Anaesthesia and positioning

Regional/general anaesthesia and patient positioned to enable good access.

Surgical technique
Landmarks and incision
The incision should be made in line with an extensile approach that can be utilised at the
time of definitive surgery to excise the biopsy tract together with the specimen.

Dissection
Dependent on the location.

Technical aspects of procedure

It is important to minimise potential complications of biopsy such as infection and
haematoma as a poorly performed biopsy carries significant morbidity. When a tourniquet
is used, the limb should be elevated rather than exsanguinated and the tourniquet deflated
prior to closure to ensure adequate haemostasis. If a drain is used, the exit point should be
in the line of any further incision.
Only one compartment of the limb should be violated during the approach. Muscles should
be split and meticulous haemostasis applied to minimise haematoma formation and
spread of fluid through tissue planes. The area to be biopsied should be carefully exposed,
taking care not to disrupt the capsule or expose more of the tumour than is necessary. If a
capsule is opened then it should be closed carefully.
16 2 Tumours

A representative sample of tissue should be taken to include the transition from normal to
abnormal tissue if possible. If there is any doubt then frozen section should be undertaken
to ensure a diagnostic specimen.

Closure
Routine.

Postoperative instructions
Neurovascular observations.

Recommended references
Ashford RU, McCarthy SW, Scolyer RA et al. Surgical biopsy with intra-operative frozen section. An
accurate and cost-effective method for diagnosis of musculoskeletal sarcomas. J Bone Joint Surg Br.
2006;88:1207–1211.
Mankin HJ, Lange TA, Sapnnier SS. The hazards of biopsy in patients with malignant primary bone and
soft tissue tumours. J Bone Joint Surg Am. 1982;64:1121.
Pollock RC, Stalley PD. Biopsy of musculoskeletal tumours – Beware. A NZ J Surg. 2004;74:516–519.

Excision of benign bone tumour

Preoperative planning
Common indications
• Impending fracture, e.g. aneurysmal bone cyst
• To prevent further bony destruction and/or functional loss in aggressive lesions – e.g.
giant cell tumour
• Mechanical symptoms – osteochondroma
• Pain – osteoid osteoma
• Risk of malignant transformation

Contraindications
No definitive characterisation of the lesion on either imaging or pathology.

Consent and risks

Depend on anatomical location and pathology of the lesion.

Templating
The approach depends on access required to perform resection while also taking into
consideration any future potential reconstructive procedures.
Another random document with
no related content on Scribd:
 TABLE

PROLOGUE 7
I. — DEUX HOMMES, DEUX CHIMÈRES 23
II. — LES CAVALIERS… 34
III. — … ET LEUR MONTURE 55
IV. — PROPOS ENTRE CIEL ET TERRE 64
V. — LE JOUR VIOLET 77
VI. — SUR LA PIERRE BRUNE 91
VII. — CEINTRAS ÉGARE SON OMBRE ET SA RAISON 101
VIII. — LA FACE AURÉOLÉE D’ÉTOILES 118
IX. — HEURES D’ATTENTE 130
X. — L’ÊTRE SE MONTRE 143
XI. — EXCURSIONS SOUTERRAINES 163
XII. — FAUX DÉPART 189
XIII. — L’AGONIE DE LA LUMIÈRE 206
XIV. — ÉCRIT SOUS LA DICTÉE DE LA MORT 226
ÉPILOGUE 233
 ACHEVÉ D’IMPRIMER
Le vingt-sept mai mil neuf cent sept
PAR

ARRAULT ET Cie
A TOURS
pour le
MERCVRE
DE
FRANCE
*** END OF THE PROJECT GUTENBERG EBOOK LE PEUPLE DU
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