Orthopedic Surgery

Each disease with the image that defines it: what it looks like, what the scan shows, and which operation answers it.

The hip fracture

An anatomical event inside a frailty syndrome.

The anatomy that decides

The femoral head's blood arrives mostly by retinacular vessels running along the neck: intracapsular fractures can strangle them, which is why displaced intracapsular fractures in older patients get replaced rather than fixed.

The operations

Extracapsular fractures keep their blood supply and are fixed, the dynamic hip screw's sliding compression is the classic; intracapsular fractures get hemiarthroplasty or total hip replacement by age, mobility and cognition.

The pathway

Analgesia with a nerve block, bloods and optimisation without perfectionism, theatre within 36 hours, then day-one mobilisation: each element has survival numbers behind it.

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The real disease

One-year mortality after hip fracture is substantial, and it is the frailty, not the femur: orthogeriatric co-management, delirium prevention, nutrition and bone protection are the other half of the operation.

Secondary prevention

A fragility fracture is osteoporosis declaring itself: bone protection medication and a falls assessment before discharge, or the next fracture is already booked.

Hip fracture fixation (dynamic hip screw)Total hip arthroplastyCase: The fall that changed the leg

X-ray

Compare with a normal hip

Prosthetic joint infection

Biofilm on metal: the arthroplasty's hardest complication.

The biology

Bacteria adhere to the implant and build biofilm, a slime city where antibiotics penetrate poorly and immune cells cannot reach: this is why 'a course of antibiotics' cannot cure an infected implant.

Presentation

Early infections are loud (wound problems, fever); late ones are quiet (pain, early loosening, a joint that never felt right): a painful arthroplasty with raised inflammatory markers is infected until the workup says otherwise.

The disciplined workup

Inflammatory markers, joint aspiration before antibiotics, culture held long enough for slow growers: starting antibiotics before sampling is the classic error that costs the diagnosis.

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Treatment strategies

Early acute infection: debridement, antibiotics and implant retention with liner exchange. Chronic infection: exchange arthroplasty in one or two stages. Every strategy is surgery plus prolonged antibiotics, chosen with microbiology at the table.

Total hip arthroplastyCase: A painful hip replacement

X-ray

• Open fractures

  A contaminated wound with a skeleton problem inside.

  Grading

  Severity scales with energy, wound size and soft-tissue loss (the Gustilo-Anderson ladder), but the honest grade is assigned in theatre after debridement, not in the ED photograph.

  The first hours

  Intravenous antibiotics as early as possible, tetanus cover, alignment and splinting, and a sealed dressing that is not lifted repeatedly for curious audiences: photographs exist so the wound is disturbed once.

  Debridement and stabilisation

  Excise the dead and contaminated until margins bleed, stabilise the skeleton (external fixation buys time when soft tissue cannot host metal), and plan cover with plastics from the first operation.

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  The orthoplastic idea

  Fix and flap as a single campaign: outcomes track the soft-tissue envelope, and the centres that do best operate bone and cover as one team on one timeline.

  Debridement and fixation of an open tibial fractureCase: Bone through the skin

• Septic arthritis

  Pus in a joint, digesting cartilage by the hour.

  How it arrives

  Haematogenous seeding into the synovium's rich blood supply, direct inoculation, or spread from neighbouring bone: Staphylococcus aureus leads, with the host's risks (diabetes, immunosuppression, prosthetics, IVDU) shaping the list.

  Why it is urgent

  Bacterial enzymes and the inflammatory response digest articular cartilage within days, and cartilage does not regrow: the clock here is measured in joint surface.

  Diagnosis

  Aspirate before antibiotics: Gram stain, culture, crystals and cell count. High synovial white counts point strongly to infection, but crystals do not acquit, since gout and sepsis can share a joint.

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  Treatment

  Washout (arthroscopic or open) plus prolonged antibiotics guided by cultures: repeat washouts are common, and the native joint's outcome tracks how fast the first one happened.

  Arthroscopic washout of septic arthritisCase: A hot, swollen knee