Osteochondritis is sometimes classified as-

1. Crushing type or Osteochondrosis
2. Osteochondritis dissecans
3. Tractions Osteochondritis or traction apophysistis

Common Osteochnodrites –

1. Perthes’ disease – Head of femur is affected
2. Panner’s disease- Capitulum affected
3. Kienbock’s disease- Lunate bone affected
4. Osgood-shlatter’s disease- Tibial tuberosity Osteochondritis
5. Sever’s disease- Calcaneal tuberosity Osteochondritis
6. Kohler’s disease- Navicular bone affected
7. Freiberg’s Disease- Metatarsal head affected
8. Scheurmann’s disease- Ring epiphyses of vertebra affected
9. Calve’s disease- Centralbody of nucleus of vertebral body affected.

Perthes’ Disease:-

Aka. Coxa Plana, Pseudocoxalgia

This is the Osteochondritis of the epiphysis of the femoral head. In the disease, the femoral head becomes partially or completely avascular and deformed as well.

Cause- not exactly known. ? recurrent ischemia of head of femur in susceptible age group. Usually precipitated by Synovitis

Age Group Susceptible- 5- 10 years                          Gender- Boys> Girls

Stages:

1. Stage of synovitis

2.Stage of Trabecular necrosis

3.Stage of healing

Presentation-

• Pain in the hip region, pain may radiate to knees.
• Hipstiffness and limping may be present
• On examination- not much findings, sometimes there is shortening of the affected limb, and the limb may be externally rotated and abducted.

X-Ray- Collapse and sclerosis od the epiphysis of the femoral head. Joint space increased- hip joint.

Bone scan- decreased uptake by femoral head.

Treatment-

Principle- preventing the Head from deforming in the softening phase, while keeping it in acetabulaum while revascularization takes place (Head Containment)

Methods- Plaster, special Braces, Splints, Operation- containment- osteotomy.

Further Reading:

AAOS

Patients Reading: patientcouk

Anatomy of Carpal Tunnel:

Carpal tunnel is a narrow passageway in the wrist formed by:

Posterior side: 8 carpal bones

Anterior side: Transverse carpal ligament

Contents:

9 Flexor tendons

Median Nerve

Median Nerve Distribution in Hand:

Origin: From lateral and medial cords of brachial plexus

Motor innervation:

Lumbricals: 1st and 2nd

Muscles of thenar eminence: Opponens pollicis, Abductor Pollicis Brevis and Flexor Pollicis Brevis)

Mnemonic: LOAF (Lumbricals, Opponens pollicis, Abductor Pollicis Brevis and Flexor Pollicis Brevis)

Sensory innervation:

Skin of the palmar side of the thumb, the index and middle finger, half the ring finger, and the nail bed of these fingers (3 and 1/2 digits)

Lateral part of the palm by palmar cutaneous nerve (unaffected in Carpal tunnel syndrome)

Carpal Tunnel Syndrome

It is a syndrome characterized by the compression of the median nerve as it passes beneath the flexor retinaculum in carpal tunnel.

Causes:

Any space occupying lesion (SOL) of carpal tunnel can cause carpal tunnel syndrome -

Inflammatory causes:

• Rheumatoid arthritis
• Wrist osteoarthritis

Post-traumatic causes:

• Colle’s fracture

Endocrine causes:

• Myxoedema
• Acromegaly

Idiopathic

Mnemonic: MEDIAN TRAP

• Myxoedema
• Edema premenstrually
• Diabetes
• Idiopathic
• Acromegaly
• Neoplasm
• Trauma
• Rheumatoid arthritis
• Amyloidosis
• Pregnancy

Clinical features:

It usually occurs in females between the age of 40 and 70. They complain of tingling, numbness or discomfort in the lateral 3 and 1/2 fingers i.e. distribution of median nerve. They also complain of intermittent attacks of pain in the distribution of the median nerve on one or both sides. The attacks frequently occur at night. The reason symptoms are worse at night may be related to the flexed-wrist sleeping position and/or fluid accumulating around the wrist and hand while lying flat. Pain may be referred proximally to the forearm and arm.

Motor changes: Ape-like thumb deformity, loss of opposition of thumb, index and middle fingers lag behind when making the fist

Sensory changes: Loss of sensations on lateral 3 and 1/2 digits including the nail beds and distal phalanges on dorsum of hand

Vasomotor changes: The skin areas with sensory loss is warmer due to arteriolar dilation; it is also drier due to absence of sweating due to loss of sympathetic supply

Tropic changes: Long-standing cases of paralysis lead to dry and scaly skin. The nails crack easily with atrophy of the pulp of fingers.

Tests

To approximate where along the wrist the median nerve runs, gently flex and radially (laterally) deviate your wrist. Two tendons will become palpable and even visible—palmaris longus (in midline) and flexor carpi radialis

(lateral to it). However, 15% of people do not have a palmaris longus muscle. The median nerve runs deep between these tendons.

Phalen’s Test:

Bend the patient’s wrists downwards as shown in the figure

This position should be held for about 1 minute.

Positive test : numbness or tingling along the median nerve distribution

Tinel’s Test:

With the palm up, tap over the carpal tunnel area of the wrist 5 or 6 times

Positive test : tingling or paresthesia in the median nerve distribution

Durkan Test:

Press thumb over carpal tunnel and hold pressure for 30 seconds.

Positive test: Onset of pain or paresthesia in the median nerve distribution

Electromyogram (EMG)

Nerve conuction studies are done for diagnosis these days

Treatment

1. Immobilizing braces/Splints
2. Analgesics like NSAIDs
3. Local injection of steroids
4. Surgery: Dividing the flexor retinaculum

Carpal Tunnel Syndrome as Occupational Disease

Causes:

1. repetitive hand motions
2. awkward hand positions
3. strong gripping
4. mechanical stress on the palm
5. vibration

Common occupations:

1. Cashiers
2. Hairdressers
3. Knitters
4. Farmers (milking cow)
5. Office workers (keyboarding)
6. Painter, etc.

May be allergic or hemolytic

1. Hemolytic reactions: can be acute or delayed

Acute Hemolytic reactions:

• It is usely due to ABO incompatibility, there is intravascular hemolysis
• As low as 10 ml of blood can produce hemolytic reactions
• Clinically, patients presents with complains of pain and burning in vein and fever with chills and rigor, nausea and vomiting, flushing, chest and flank pain and dyspnea.
• It is confirmed by hemoglobinuria
• ARF can occur due to blockage of tubules

Management:

• Stop infusion
• Recheck the blood details
• Maintain urine output by mannitol and fruit administration
• Alkalinize urine
• Hemodialysis

Delayed Hemolytic Reactions:

• Are extravascular hemolytic reactions
• Mainly due to Rh system and other system incompatibility eg. Kell Duffy
• These reactions are mild and seen after 21 days
• Diagnosed by Coomb’s test
• Treatment is supportive

2. Allergic reaction:

• These are mainly mild, seen as urticaria and are mainly due to plasma proteins
• Treatment is antihistaminics and steroids
• If anaphylaxis occurs, stop transfusion
• Adrenaline and steroids

B. Febrile Reactions:

Due to infusion of white cell microaggregates
Can be minimized by using microfilter blood sets with pore size 20-40 micrometer
Generally require no treatment

C. Infectious Complications:

• Hepatitis: 90% are due to hepatitis C virus
• HIV/AIDS
• Other viral diseases like CMV, EBV, HTLV-1, HTLV-2, parvovirus
• Bacterial infections like Pseudomonas, Staphylococcus, Syphillis, Brucellosis, Salmonella, Yirsenia and rickettsial disease
• Parasitic infections like malaria, toxoplasmosis, filariasis, trypanosomiasis, Creuz-Jackobs Disease (prion)

D. Fluid Overloading and Pulmonary Edema

E. Metabolic Complications:

• Hyperkalemia
• Hypocalcemia
• Acid-base abnormalities

F. Coagulation abnormailities:

Occurs due to dilution of coagulation factors and platelets
Treatment is fresh blood
Fresh frozen Plasma
Specific blood components therapy
Platelets

G. Hypothermia: Blood should be warmed before use

H. Immunosuppression- graft vs host reaction

I. Tissue hypoxia – due to shift of oxygen dissociation curve to left due to decreased 2,3 DPG

J. Endotoxaemia and Septicaemia

K. ARDS (Acute Respiratory Distress Syndrome) – now known as TRALI (Transfusion Related Acute Lung Injury)

L. Disseminated Intravascular Coagulation (DIC)

Due to convenience, Laparoscopic cholecystectomy has now replaced open cholecystectomy as the first-choice of treatment for gallstones and inflammation of the gallbladder unless there are contraindications to the laparoscopic approach.

Several small incisions in the abdomen to allow the insertion of operating ports, small cylindrical tubes approximately 5-10 mm in diameter, through which surgical instruments and a video camera are placed into the abdominal cavity.
The camera illuminates the surgical field and sends a magnified image from inside the body to a video monitor, giving the surgeon a close-up view of the organs and tissues. The surgeon watches the monitor and performs the operation by manipulating the surgical instruments through the operating ports.

Laparoscopic cholecystectomy is now the gold standard for the treatment of symptomatic gallstone disease. It is most commonly performed Minimal Invasive Surgery by General surgeon’s world wide.

Common Indications are:

• Cholelithiasis
• Mucocele gall bladder
• Empyema ball bladder
• Cholesterosis
• Typhoid carrier
• Porcelain gallbladder
• Acute Cholecystitis (calculous and acalculous)
• Adenomatous gall bladder polyps
• As part of other procedures viz. Whipple’s procedure

Advantage of laparoscopic approach:

• Cosmetically better outcome.
• Less tissue dissection and disruption of tissue planes
• Less pain postoperatively.
• Low intra-operatively and postoperative complications.
• Early return to work.

Pre-operative Investigations:

Apart from routine pre-operative investigations, in fit patients, the only investigations needed are ultrasound examination, although practiced in some centers; intravenous Cholangiography may not be confirmative and is attended with the risk of anaphylactic reactions.

Relative contra-indications:

• Complicated Cholecystitis.
• Poor risk for general anaesthesia.
• Some cases of previous extensive abdominal surgery.

1. Patients with severe cardiac diseases and COPD should not be considered a good candidate for laparoscopy. The laparoscopic cholecystectomy may also be more difficult in patients who have had previous upper abdominal surgery. The elderly may also be at increased risk for complications with general anaesthesia combined with pneumoperitoneum.
2. Patient position:Patient is operated in the supine position with a steep head-up and left tilt once the pneumoperitoneum has been established.
3. Position of Surgical team:The surgeon stands on the left side of the patient with the scrub nurse-camera holder-assistant. One assistant stand right to the patient and he will hold the fundus grasping forceps.

Procedure:

1. Preparation of the patient.
   
2. Creation of pneumoperitoneum.
3. Insertion of ports
4. Diagnostic laparoscopy
5. Dissection of visceral peritoneum
6. Dissection of Calot’s triangle
7. Clipping and division of cystic duct and artery
8. Dissection of gallbladder from liver bed.
9. Extraction of gallbladder and any spilled stone.
10. Irrigation and suction of operating field.
11. Final Diagnostic laparoscopy.
12. Removal of the instrument with complete exit of CO2.
13. Closure of wound.

OT instruments for Laparoscopic Cholecystectomy

Port location

Four ports are used: optical (10mm), one 5mm and one 10mm operating, and one 5.0mm assisting port. The optical port is at or near the umbilicus and routinely a 30 laparoscope is used. Some surgeon who has started laparoscopy earlier they are more comfortable with 0 degree telescope.

First view of gallbladder after insertion of telescope

Once all the four ports are in position the fundus of the gallbladder is grasped by the assistant and flipped upwards and over the superior edge of the right lobe of liver.

Dissection of Cystic Pedicle
Any adhesion should be cleared from the gallladder. Sharp dissection may be carried out with the help of scissors attached with monopolar current. At the time of separating adhesion surgeon should try to be as near as possible towards gallbladder. The cystic pedicle is a triangular fold of peritoneum containing the cystic duct and artery, the cystic node and a variable amount of fat. It has a superior and an inferior leaf which are continuous over the anterior edge formed by the cystic duct. An important consideration is the frequent anomalies of the structures contained between the two leaves (15 -20%). The normal configuration is for an anterior cystic duct with the cystic artery situated postero-superiorly and arising from the right hepatic artery usually behind the common bile duct.

Pledget dissection of Cystic pedicle

The dissection of the cystic pedicle can be carried out with two handed technique. The dissection should be started with antero-medial traction by left hand grasper placed on the anterior edge of Hartmann’s pouch, The antero-medial traction by left hand will expose the posterior peritoneum. The peritoneum of the posterior leaf of the cystic pedicle is divided superficially as far back as the liver. Posterior leaf is better to dissect before anterior leaf because it is relatively less vascular & the bleeding if any, will not soil the anterior peritoneum, whereas if anterior peritoneum is tackled first it my make the dissection area of posterior peritoneum filled with blood making dissection of this area difficult. Once the visceral peritoneum is dissected a pledget mounted securely in a pledget holder is used for blunt dissection.

Separation of Cystic artery from Cystic duct
The separation of the cystic duct anteriorly from the cystic artery behind can be performed by a Maryland’s grasper by gently opening the jaw of Maryland between the duct and artery. The opening of the jaw of Maryland dissector should be in the line of duct never at right angle to avoid injury of artery behind. Sufficient length of the cystic duct and artery on the gallbladder side should be mobilised so that three clips can be applied.

Clipping of cystic artery
The cystic artery is clipped and then divided by hook scissors. Two clips are placed proximally on the cystic artery and one clip is applied distally. The artery is then grasped with a duckbill grasper on the gallbladder wall and then divided between second and third clip.

The dissection of the cystic pedicle is completed by placement of a clip to occlude the cystic duct at its junction with the gallbladder.

Operative Cholangiogram

In many institutions routine operative cholangiogram is performed. Routine cholangiogram decreases the risk of CBD injury in case of difficult anatomy. The opening in the cystic duct in made on the antero-superior aspect. Correct alignment of the cystic duct and infusion of saline facilitates insertion of ureteric catheter to perform cholangiography. Insertion is difficult if the opening in the cystic duct is made too close to the gallbladder. The contrast medium should be injected slowly during screening and the patient should be in a slight trendelenberg position with the table rotated slightly to the right. It is essential that the entire biliary tract is outlined. Surgeon should ligate or clip cystic duct when you are sure up to the point of absolute certainness.

Ligation of Cystic Duct

Although the majority of surgeons opt for clipping the cystic duct, before dividing it, this technique though quick is intrinsically unsound as internalisation of the metal clip inside the common bile duct over the ensuing months is well documented. There is report of internalization of clip and subsequent stone formation after many years. The internalised clip becomes covered with calcium bilirubinate pigment. For this reason, to tie the cystic duct using a catgut Roeder external slip knot should be done.

Dissection of Gallbladder from Liver Bed

Gallbladder should be seperated from the liver through the areolar tissue plane binding the gallbladder to the Glisson’s capsule lining the liver bed. The actual separation can be performed with scissors with electrosurgical attachment or electrosurgical hook knife. Pledget can be used to remove the gallbladder from liver bed once a good plane of dissection is found. Perforation of the gallbladder during its separation is a common complication which is encountered in 15% of cases.

One should be careful at the time of dissection and if there is spillage of stone each stone should be removed from the peritoneal cavity to avoid abscess formation in future.

Extraction of Gallbladder

The gallbladder is extracted through the 11 mm epigastric operating port with the help of gallbladder extractor. Many surgeons use umbilical port for withdrawal of gallbladder. First the neck of the gallbladder should be engaged in the cnula and then canula will withdraw together with neck of gallbladder held within the jaw of gallbladder extractor. Once the port with the neck of the gallbladder is out the neck is grasped with the help of a blunt hemostat and it shoud be tried to pull out with screwing movement. If gallbladder is of small size it will come without much difficulty otherwise small incision should be given over the neck of the gallbladder and suction irrigation instrument should be used to suck all the bile to facilitate easy withdrawal.

Some time big stones will not allow easy passage of gallbladder and in these situation ovum forceps should be inserted inside the lumen of gallbladder through the incision of its neck and all the stone should be crushed.

The Instrument and then ports are removed. Telescopic should be removed leaving gas valve of umbilical port open to let out all the gas. At the time of removing umbilical port telescope should be again inserted and umbilical port should be removed over the telescope to prevent any entrapment of omentum. The wound should be closed with Suture. Vicryl should be used for rectus and Un-absorbable intra-dermal or Stapler for skin. Some surgeon likes to inject local anaesthetic agent over port site to avoid post operative pain. Sterile dressing over the wound should be applied.

Specimen of Gallbladder After Laparascopic Cholecystectomy

Complications:
Early complication:

1. Common bile duct injury
2. Bile leak
3. Injury to viscera
4. Hemorrhage
5. Retained stones and abscess formation

Late complication:

1. Biliary strictures
2. Cystic duct clip stones
3. Hemorrhage

Watch the Video Here-