POSTOPERATIVE MANAGEMENT OF ORTHOPEDIC PATIENTS

THE SURGEONS PERSPECTIVEED SZALAPSKI JR., M.D.

TWIN CITIES ORTHOEDICS

PHYSIOLOGIC RESPONSE TO TRAUMA

• VASODILATION• INCREASED MEMBRANE PERMEABILITY• THIRD SPACING• FLUID RETENTION

RESULT

• PATIENTS REQUIRE VOLUME SUPPORT• LOW BP• LOW URINE OUTPUT• ORGAN DAMAGE• RENAL FAILURE

MODIFIERS

• GENERAL HEALTH• MEDICATIONS• LOCATION OF SURGERY• MAGNITUDE OF DISSECTION• OUR INTERVENTIONS

RECOVERY

• AS PATIENTS RECOVER, THEY MOBILIZE/REABSORB FLUIDS

• INCREASED URINE OUTPUT• OCCASIONAL FLUID OVERLOAD

PRIMARY HIP REPLACEMENT

CMS CHECKSBLOOD LOSSURINE OUTPUT/RENAL FUNCTIONBLOOD PRESSURE (HTN MEDS!)DISLOCATIONS

PRIMARY KNEE REPLACEMENT

• PAIN MANAGEMENT!!!!!• BLOOD LOSS (250 TO 1250 ml)• URINE OUTPUT/RENAL FUNCTION• MOTION• VITAL SIGNS (HTN MEDS)

PATELLA FRACTURE

• MINIMAL DISSECTION• MINIMAL BLOOD LOSS• STRAIGHTFORWARD PAIN MANAGEMENT• MINIMAL THIRD SPACING• NON-WEIGHT BEARING• PATIENT STRENGTH & MOBILITY FACTORS

TIB FIB FRACTURE

• BLOOD LOSS IS USUALLY MILD• THIRD SPACING IS USUALLY MILD• PAIN MANAGEMENT• COMPARTMENT SYNDROME!!!!

COMPARTMENT SYNDROME

PRESSURE WITHIN THE FASCIAL COMPARTMENT RISES ABOVE PRESSURE WITHIN THE SMALL VESSELS

ISCHEMIARAPID ONSET OF PERMANENT DAMAGE TO

MUSCLE AND NERVES

COMPARTMENT SYNDROME

• PAIN, PAIN, PAIN• LOSS OF ACTIVE MOTION• PAIN WITH PASSIVE MOTION• LOSS OF PULSE IS TOO LATE• LOSS OF PERFUSION IS TOO LATE• BEDSIDE PRESSURE MEASUREMENT• SURGICAL EMERGENCY

INTERTROCHANTERIC HIP FRACTURE

• BLOOD LOSS DEPENDS ON DISPLACEMENT AND COMMINUTION

• BLOOD LOSS IS HIDDEN IN THIGH MUSCLES, NOT IN THE DRAIN, IF ANY

• WATCH THE URINE OUTPUT• WATCH THE VITALS

PERIPROSTHETIC FRACTURE

• MODERATE BLEEDING AND THIRD SPACING• LOW CMS RISK• NON WEIGHT BEARING• MOTION• MODERATE PAIN

PERIPROSTHETIC FRACTURE

• EXTENSIVE DISSECTION• MAJOR BLOOD LOSS AND THIRD SPACING• GREAT DEAL OF DRAINAGE• WATCH URINE OUTPUT• THIRD SPACING

SEPTIC TOTAL KNEE

• 84 YO MALE• DIABETIC• HTN• VENOUS STASIS• SEVERAL WEEKS OF DENIAL

REIMPLANTATION

• QUADRICEPS TURNDOWN—RESTRICTED MOTION AND WEIGHT BEARING

• THREE UNITS OF BLOOD• MILD ACUTE RENAL FAILURE• MILD CHF SEVERAL DAYS LATER

SEPTIC TOTAL HIP

• 60 YO MALE• PRIOR IM NAIL• 300+ POUNDS• MRSA INFECTION• VANCOMYCIN ALLERGY• THREE DEBRIDEMENTS TO ERADICATE

INFECTION

HIP REIMPLANTATION

• 8 UNITS PRBC• 10 LITERS OF FLUID• PRESSORS FOR 12 HOURS• MILD RISE IN Creatinine—resolved• FULL WEIGHT BEARING

SUMMARY

• IT’S NOT JUST THE BONES• THINK ABOUT GENERAL PHYSIOLOGY OF

SURGERY

CONFLICT OF INTEREST

I hereby certify that, to the best of my knowledge, no aspect of my current personal or professional situation might reasonably be expected to affect significantly my views on the subject on which I am presenting.