What is the approach to orthopedic surgery?

Approach to Orthopedic Surgery

The approach to orthopedic surgery should follow a damage control strategy in cases of severe trauma, with temporary stabilization followed by delayed definitive osteosynthesis once the patient is clinically stable to reduce morbidity and mortality. 1

Initial Assessment and Decision-Making

Orthopedic surgery encompasses the diagnosis and treatment of musculoskeletal conditions across all age groups. The approach varies significantly based on the urgency of the condition:

Trauma Cases

• Hemodynamically unstable patients: Implement damage control orthopedic surgery (DCO)

  • Use temporary stabilization (external fixator or skeletal traction) for femoral and tibial shaft fractures
  • Delay definitive osteosynthesis until patient stabilization (typically within 24-48 hours) 1
  • Monitor for circulatory status, respiratory function, coagulation, and acid-base balance

• Hemodynamically stable patients: Consider early definitive fixation if no contraindications exist

Limb Salvage vs. Amputation

• In hemodynamically stable patients, limb salvage is generally recommended 1
• No single gravity criterion mandates amputation, though factors such as complete traumatic amputation, large tissue loss, proven tibial nerve section, and multiple fractures with bone loss may favor this approach
• Mangled Extremity Severity Score (MESS) alone should not dictate amputation decisions 1

Elective Orthopedic Procedures

Evidence-Based Decision Making

• Many common elective orthopedic procedures have limited high-quality evidence supporting their effectiveness 1
• Consider non-operative care as first-line treatment for conditions where evidence shows equivalence to surgical intervention
• Surgery may be appropriate as second-line treatment when non-surgical measures fail 1

Preoperative Optimization

• Evaluate and correct preoperative anemia to reduce perioperative morbidity and mortality 1
• Implement thromboprophylaxis strategies:
  • For major orthopedic surgery, extend thromboprophylaxis for up to 35 days post-surgery 1
  • Consider dual prophylaxis with antithrombotic agents and intermittent pneumatic compression devices during hospital stay 1
  • For patients with increased bleeding risk, use mechanical prophylaxis rather than pharmacological treatment 1

Prosthetic Joint Infection Management

For patients with prosthetic joint infections (PJI), follow a structured approach:

• Debridement without prosthesis removal: Consider for early postoperative PJI (<30 days) or short-duration hematogenous infections with well-fixed prosthesis 1
• Two-stage exchange: Preferred for chronic infections or those with resistant organisms 1
• One-stage exchange: Consider for total hip arthroplasty infections with known pathogens susceptible to oral antibiotics and good soft tissue envelope 1
• Permanent resection arthroplasty: Consider for non-ambulatory patients, limited bone stock, poor soft tissue coverage, or highly resistant organisms 1

Special Considerations

Pediatric Orthopedics

• Elective surgical treatment should only be performed after maximizing medical treatment for at least 12 months 1
• Consider age as an important factor in surgical decision-making 1
• Surgery should be performed by surgeons with expertise in metabolic bone diseases 1
• Mechanical axis deviation (Zone 2 or greater) despite optimized medical treatment may warrant surgical intervention 1

Common Pitfalls to Avoid

1. Premature definitive fixation: In polytrauma patients, early definitive osteosynthesis can increase complications. Follow damage control principles when appropriate.

2. Overreliance on scoring systems: While tools like MESS can guide decision-making for limb salvage, they should not be the sole determinant.

3. Underestimating infection risk: Ensure proper antibiotic prophylaxis and sterile technique, particularly for implant surgeries.

4. Inadequate thromboprophylaxis: VTE is a significant risk in orthopedic surgery; ensure appropriate prophylaxis based on patient risk factors.

5. Overlooking preoperative optimization: Address modifiable risk factors like anemia, diabetes control, and nutritional status before elective procedures.

The field of orthopedic surgery continues to evolve, with increasing emphasis on evidence-based approaches, minimally invasive techniques, and patient-specific treatment plans. Following these structured approaches can help optimize outcomes while minimizing complications.