Complications of orthopaedic surgery

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Orthopaedic surgery is undertaken to achieve specific surgical goals that improve function and relieve musculoskeletal discomfort. However, complications can occur which have the potential to significantly affect both short term and long-term outcomes. This chapter provides information on defining complications, prevention and minimization of complications, signs of complications and types of complications.

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16.3 The presence of pre-existing infection can greatly increase the risk of surgical site infection. This dog was presented for total hip replacement but pyoderma was noted after clipping of the hair coat. In this circumstance, antibiotic therapy should be started and elective surgery postponed until the pyoderma is resolved.
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16.6 (a) Bending of the proximal bone screws applied during a partial tarsal arthrodesis procedure in a cat. Acute overload resulted in implant deformation and lateral deviation at the level of the tarsometatarsal joint. (b) Pull-out of the bone screws (bone–implant interface failure) from the proximal femur that occurred as a result of an excessively stiff bone plate for this animal (2.7 mm dynamic compression plate) in combination with excessive lever arm bending due to too short a plate. (c) This was subsequently revised using a longer and less rigid bone plate (2.0 mm veterinary cuttable plate) supported by an intramedullary pin.
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16.7 (a) Plate failure has occurred through an empty plate hole following cyclic loading, i.e. repetitive loading with low magnitude forces. Stresses concentrate within the metal, resulting in work hardening, fissuring and crack propagation. (b) Screw breakage following locking plate fixation using a String of Pearls bone plate combined with an intramedullary pin. This occurred as a result of stress concentration at the interface between the screws and the plate.
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16.8 The 3.5 mm non-locking cortical bone screw shown on the left (Synthes) has a 2.4 mm diameter core, whereas the 3.5 mm locking screw on the right (Synthes) has a larger 2.9 mm core diameter. As the resistance (R) to bending is proportional to the radius (r) of the screw (R = r ), the 21% increase in core diameter results in a substantial but disproportionate 213% increase in bending strength and resistance to fatigue failure.
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16.9 (a) Tibial fracture has occurred following tibial tuberosity transposition in a 5 kg Bichon Frise as a result of stress concentration at the base of the tibial tuberosity. (b) The fracture was initially revised by application of an excessively large and rigid implant that did not span the length of the bone, which (c) subsequently refractured. (d) This was revised by placing a less rigid veterinary cuttable bone plate (Synthes) that spanned the whole of the tibial diaphysis. (e) A similar fracture that occurred 5 days after tibial tuberosity advancement surgery using the MMP technique in an English Springer Spaniel. (f) Orthogonal bone plates were applied to stabilize the fracture and maintain tibial tuberosity advancement.
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16.10 An external fixator has been applied in an attempt to treat a tibial fracture. The principles of external fixator application have not been followed: the fixation pins are concentrated around the fracture and the two proximal pins cross in the diaphyseal bone very close to the fracture. Long sections of diaphyseal bone are unsupported creating excessive lever arm forces at the level of the implants, resulting in fracture at the proximal pin tract.
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16.11 (a) A 2-year-old Border Collie with a non-functional malunion following antebrachial fracture sustained as a puppy. (b) A volume rendered three-dimensional computed tomography (CT) reconstruction of the bone was used to plan a corrective osteotomy.
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16.12 Exposure of the bone plate has occurred following a pantarsal arthrodesis procedure. This is likely to have resulted from excessive wound tension, self-trauma or postoperative swelling. Granulation and epithelialization will often occur around the margins of the viable soft tissue; however, it can be difficult or impossible to completely close the skin defect. Implant removal after osseous union has occurred will frequently allow soft tissue healing; however, re-fracture or breakdown of arthrodesis at one or more levels are possible consequences.
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16.13 Plantar necrosis has occurred following partial tarsal arthrodesis. The cause of such severe loss of tissue is likely to be multifactorial. Excessive tissue swelling and overly tight dressing application probably contribute to this catastrophic complication. Injury to the perforating metatarsal artery during medial plate application or debridement of the tarsometatarsal joints has also been suggested as a possible cause. While some dogs will regain functional limb use following extensive and prolonged wound management, the prognosis is poor.
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16.14 (a) This dog developed a discharging sinus several months after the stabilization of a humeral condylar fracture. (b) Surgical exploration of the sinus was performed and resulted in the excision of the nylon suture.
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16.15 An excessively tight distal limb dressing had been applied several days earlier, resulting in progressive necrosis of the paw. There was no sensation to the distal limb and no active bleeding was evident after making small incisions into the affected tissues. Amputation was necessary.
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16.16 (a) Swelling of the distal extremities frequently occurs if the digits are not enclosed within the dressing. (b) The incidence of complications, such as rubbing between the digits, may be reduced by placing padding between the digits and enclosing the toes. (c) A small gap can be left at the end of the dressing to allow assessment of perfusion to the claws and digits.
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16.17 A severe full thickness pressure sore on the lateral aspect of a cat’s paw following prolonged dressing application. Cast sores and rubs are common following the prolonged use of external coaptation. It is important to relieve pressure over the sore and prevent further abrasion from occurring. Often removal of the dressing is the most expedient way of treating dressing-related injuries.
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16.18 (a–b) Reduction in bone density can develop rapidly following external coaptation in young animals. Note the reduction in bone density between the two images that was associated with external coaptation of only 1 week’s duration.
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16.19 Stifle flexion device for the management of quadriceps contracture. (Courtesy of A Moores)

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