Department of Orthopaedics AAU MBBS

Nwokke O C FMCS, FWACS –(Lectures)

Topic: Introduction to Orthopaedics

Orthopaedics is a specialty of surgery that deals with disorders of the
musculoskeletal system and trauma to the musculoskeletal system.

The term Orthopaedic was coined by Nicholas Andre in 1741

It is derived from two composite Greek words

 Orthos – straight
 Paidio - child

Orthopaedics literarily means ‘straight child ‘. Ancient Orthopaedics was practiced

by the Greeks, Egyptians and Romans. Amputations’ were performed and
primitive prosthesis used. Fractures were managed and it healed in fair
alignment using splints of Bamboo and reeds padded with linen; Hippocrates
developed manipulations and traction method for joint dislocation that is of use
till date.

Modern era Orthopaedics can also be linked with the industrial revolution ,
introduction of better control of infection , invention of X ray and other
Radiological technology like CT and MRI as well as advances in metallurgy.

Orthopaedics is currently practiced under the following Sub specialization .

 Sports medicine and arthroscopy deals with injuries of joints arising from
sports and the use of arthroscope for diagnosis and repair of such injuries
 Arthroplasty : Replacement of articulating parts of a Joint owing to
diseases or fracture
 Oncology : management of neoplasm’ of the musculoskeletal system
 Paediatrics orthopedics’ :- this deals with orthopaedic conditions in
children
 Spine :- management of vertebral spine lesion; typically lower Cervical
spine to the sacrum
Lecture 2: Septic Arthritis
O.C Nwokike fmcs, fwacs

 DEFINITION
 ANATOMY OF A JOINT
 AETIOLOGY
 PATHOGENESIS
 CLINICAL FEATURE
 EXAMINATION
 INVESTIGATION
 TREATMENT
 REHABILITATION
 PROGNOSIS

DEFINITION AND INTRODUCTION

 Septic arthritis is an infective inflammatory condition of the joint’s

articulating surfaces and the synovial membrane. It is an Orthopaedic
emergency that could lead to complete destruction of the joint if not
quickly and properly treated.

ANATOMY OF THE JOINT:

 A typical joint consist of the articulating bone covered with Hyaline

cartilage and enveloped by synovial membrane. This is further enclosed by
joint capsules with, ligaments and surrounding tendons and muscles.
AETIOLOGY

 Staphlococcus auerus most common, others are Escherichia Coli,

Streptococci species and other Gram –ive Bacilli. Salmonella is common
among HbSS conditions
 Mycobacterium Tuberculosis

PATHOGENESIS

 Organisms gets to the Joint by

(1)Heterogeneous spread through the process of septicemia
(2)Contiguous spread by nearby septic focus
(3) Direct inoculation e.g puncture wounds,.
(4) Iatrogenic – use of non sterile materials -Joint Aspirations

CLINICAL FEATURES –

The Typical presentation is Fever, Pain and swelling around the affected joint. As
it progresses Joint Range of motion is impaired with a background of a very ill
child

Exammination:- The Joint is typically swollen , shining joint , look out for
scarifications , and lesions around the joints .Pay attention to the attitude of the
joint . The Child avoids any kind motion around the affected joint.

Hip is flexed, abducted and externally rotated, while the knee is partially flexed ,
Joint Tenderness is marked , movement elicits severe pain .
INVESTIGATION

 FBC+Esr- leucoytosis and elevated ESR

 X ray –widened joint space(early stage) due to joint effusion
-narrowed joint space(later stage) due to cartilage destruction
 USS- fluids in the joint space(joint effusion)
 Color doppler- increased perisynovial vascularity
 Diagnostic Aspiration – Yield pus
 MCS will isolate and culture the organisms
DIFFERENTIAL
 Reactive arthritis e.g viral infections
 Hemaathrosis
 Heamoglobinopathy(sickle cell vaso-occlusive crisis)
 Acute osteomyelitis
TREATMENT
 splintage / Tractions – provide rest and comfort
 Antibiotics based on sensitivity
 Surgery :- Arthrotomy , joint washout .
 Rehabilitation – Early physiotherapy is advised
COMPLICATIONS
Joint Ankylosis , joint destruction , osteomyelitis .
Lecture 3 Chronic Osteomyelities
O.C Nwokike fmcs, fwacs

 DEFINITION
 AETIOLOGY /PATHOGENESIS
 CLINICAL FEATURE
 EXAMINATION
 INVESTIGATION
 TREATMENT
 REHABILITATION
 PROGNOSIS
 Definition
 This is an infection of the bone and bone marrow lasting more
than 2 weeks, and characterized by the presence of infected
dead bone within a compromised soft tissue envelope .
It can also be defined as
 A progressive inflammatory bone disease caused by pathogens resulting in
bone destruction and sequestrum formation
AETIOPATHOGENESIS
The disease may set off as
1. Progression from Acute Osteomyelitis
2. Open fracture
3. Post operative
4. Chronic infection- tuberculosis , fungi Actinomycosis
There is severe vascular compromises, ischemic changes, sepsis, dead bone and
new bone formation which unfortunately also get infected perpetuating this
infective process. The dead bone acts as a safe haven, shielding the organisms
from antibiotics and body immune mechanisms (note that any foreign body in the
bone eg implant does the same) the organisms can also be entombed or go into
dormancy for many years only to be reactivated. Chronic osteomyelities is
difficult to eradicate and can last a life time. In very few situations however, it can
run a self limiting course with the dead bones extruded spontaneously or with
wound dressings.
As the disease progresses , the Devascularized dead bone is sequestered out
following new bone formation , it is called the Sequestrum , the new bone
regenerates is known as Involucrum. there may be defects on the bone , these
defects are called Cloaca .

CLINICAL FEATURES
-Recurrent bone pain,
-Recurrent discharges,
-Recurrent swelling,
-Recurrent ulceration,
-Occasional extrusion of bone particles etc.
History of fever and swelling may be suggestive of proceeding acute
oseomyelities .
Open fractures, post implant surgery, deformity, history of DM, Hbss, HIV ,
Malignancy , steroid use .
 Affected part often looks atrophic, hyper pigmented, may be swollen, may
show multiple scars indicating sites of healed sinuses , may also have active
draining sinuses .
 Investigation –
FBC – may be normal
wound MCS – may not be representative if taken from the sinus opening- mixed
organism are common , Staph, Strep , Pseudomonas are common isolates
X ray – look out for sequestrum, involucrum , access extent of disease ,
pathological fracture may also be seen .
CT, MRI- are not routine, may add further information on the bone viability and
soft tissue vascularity

TREATMENT :
Medical
1. Good nutrition to boost immunity
2. Antibiotics therapy – aim is control acute flares , prevent spread of
infection ,
3. Post surgical antibiotics therapy must extend for 4-6 weeks
Surgery is the main stay
 Surgical treatment may be
(1)Incision and drainage
(2)Sequestrectomy and saucerization – we remove all sequestrums ,
(3)Radical Excision and Ilizarov /Bone transport typical for infected non union
(4)Amputation
 Challenges of surgery include
 1. Antibiotics delivery – Antibiotics beads , irrigation by Lautenbach
technique
2. Dead space management :- Muscle flaps overlays, Belfast procedure –
delayed bone graft , Papineau technique bone graft procedure
3. Bone Gap: - Vasularised bone graft , Bone transport / Ilizarov
SPECIAL CASES

 INFECTED IMPLANT –it is advised to retain implant except if infection is

overwhelming or implant is loose and not holding
 Sub acute Osteomyelitis :- seen where the organism is less virulent or Host
immunity is strong , presents with milder form of osteomyelitis eg
Sclerosing Osteomyelitis of Garre

PROGNOSIS
prognosis is Good in chronic osteomyelities , however the sinus Ulcers have a risk
of malignant transformation (marjolins ulcer)
Lecture 4: Angular deformities around
the knee
O.C Nwokike fmcs, fwacs

Angular deformities around the knee are deformities which shifts the mechanical
axis from the normal. These deformities are largely in the frontal or Sagittal
plane , but also may include torsional deformity .
The mechanical Axis of the lower limb is defined as the line of force or weight
bearing of the Lower limb. It is represented by an imaginary line which runs from
the center of the femoral head to the center of the Talus.
This line (mechanical axis) should pass through the center of the knee ;
 Varus Deformity results If this line falls more medial than the center of the
knee ,
 Valgus deformity results if it falls more lateral than the center of the knee.
Note that the mechanical axis of the lower limb is different from the Anatomical
axis of the lower limb.
The Anatomical axis of the lower limb is the Axis of the shaft of the Tibia and
Femur . While the Femoral Anatomical axis is 6 degree from the mechanical
axis, the Tibia anatomical axis coincides with the tibia mechanical axis. This is
useful in understanding and defining angular deformity around the knee .

Angulation may also occur in the sagittal plane. This gives rise to
  Anterior angulation or
 Posterior angulation

CAUSES OF ANGULAR DEFORMITY

Physiologic Angular deformity:
This is seen in infants at Age 0-1 year As Varus , it progressively begins to
(resolve) straighten . At about 2yrs of age it may become completely neutral. it
then tends to a valgus attitude and by age 4yrs and gets to its peak valgus of
about 12 degree. Again it begins to spontaneously resolve ( correct ) and the
valgus angulation starts to decline to settle at normal adult position of 3-5
degree valgus in male and 3-7 degree in female . This should be attained by the
age of 9yrs.
TREATEMENT OF PHYSIOLOGIC VARUS/VALGUS :-
 Physiological Angular deformity is self limiting.
 Re assurance only after adequate investigation and all pathology excluded
 Watchful waiting
If by pre adolescence age of 12yrs , the intercondyler distance is more than 6cm
(Distance between the left and right medial tibia condyles) or the inter
malleolar distance is more than 8cm ( distance between the right and left
medial malleolus) surgical treatment is required:
 epiphyseal stapling ,
 epiphysiodesis ,
 osteotomy
PATHOLOGIC ANGULAR DEFORMITIES:- This results from various pathology
which affect normal bone growth

(1) Blount disease --- ( characteristically Varus )

 infantile
 Juvenile
 Adolescence
(2) Physeal injuries
 Trauma
 Infection
 Tumours
(3) Metabolic
 Vit D deficiency ( Nutritional Rickets )
 Vit D resistant Rickets
 Hypophosphatasia
(4) skeletal dysplasis
 Achondroplasias
 Metapyseal chondrodysplasia
 Multiple epiphyseal dysplasia

Blount Disease:-
It is a disease of unknown aetiology , found mainly in people of Africa descent.
Blount disease is characterized by progressive varus deformity due to unequal
growth of the posteromedial half compared to the lateral half of the proximal
tibia physial growth plate(epiphysis).
Based on age of onset, it is divided into
 infantile – <4yrs ,
 juvenile 4- 10yrs
 Adolescence 11yrs.
It tends to be bilateral and more severe in the infantile / juvenile types, The
severity is determined by duration of disease, obesity and quality of care.

The retardation in growth of the posteromedial part of the medial physis has
been attributed to compression forces. Eventually, with loading, the medial
epiphysis flattens, slops down, the metaphysis beaks and the physeal plate closes
prematurely when a bony bar grows across the medial physial plate
The disease progresses until the skeletal maturity is attained.
 Investigation : plain radiograph of the knee Ap/Lat views will diagonize the
condition in majority of cases . However there may be need for ancillary
investigations to exclude other metabolic causes of angular deformity
 TREATMENT
Treatement is surgical -
Osteotomies eg
1. lateral based , closing wedge , proximal tibia osteotony
2. Dome osteotomy
3. Ilizarov device fixation

Rickets :
Essentially a metabolic bone disease due to lack of Vitamin D or Calcium, this
causes poor mineralization of bone. It affects all physeal plate. It is a major cause
of Varus or Valgus deformity of the knee. Owing to poor mineralization, the knee
caves in under the influence of weight.
These deformities revert spontaneously when nutritional balance is restored.
However in few instances there remains a residual unacceptable deformity.
Metabolic conditions must be treated first. Surgical correction is only indicated
in a burnt out Rickets with residual deformity.
Other clinical features of Rickets such frontal bossing, flaring of the distal Radius
etc may be pointer of active rickets.
INVESTIGATION
Metabolic work up is advised viz serum calcium, serum phosphate , Alkaline
phosphate .
X ray of the knee
Treatment is surgical-
 corrective osteotomy
 epiphyseal stapling

Epiphysealinjuries / infection
Any partial violation of the physis will lead to Angular deformity this is due to
unequal growth. The violation of the physeal anatomy may be due to infection,
trauma or tumour
TREATMENT
Treatment is by
 excising the physeal bony bar and grafting with fat ,
  Epiphyseal stappling
 Epiphysiodesis ,
 Corrective osteotomy

Complications of corrective osteotomy

 Compartment syndrome
 Injury to common peroneal nerve
 Injury to blood vessels
 Non union may also occur

Ilizarov treatment .

It is an advanced treatment of angular deformity, this is the gold standard. It has

the capacity to correct all deformities in all planes at all age in addition to limb
lengthening.