ORTHOPAEDIC DECISION

MAKING

APPLICATION OF BASIC BIOLOGICAL

FACTS
IMPORTANCE OF DECISION
MAKING
 Gives a broad idea about the expected
outcome of the condition
 Gives a direction to the treatment plan
 Avoids delay in the definitive treatment
 Utilizes the biologically favorable
opportunity at the right time.
TIMING OF DECION MAKING
 Too hasty?

 Too much of delay?

 Avoiding to decide?
STEPS IN DECISION MAKING
 Thorough, relevant clinical examination
 Establishment of a clinical diagnosis or an
etiological category.
 Urgency of the situation
 Relevance and feasibility of investigations
 Best modality of treatment
STEP 1- ESTABLISHING THE
AETIOLOGY
THE BASIC CAUSE OF THE CONDITION.
 CONGENITAL?
 INFECTIVE? \INFLAMMATORY?
 TRAUMATIC/ SUPERIMPOSED
TRAUMA?
 NEOPLASTIC?
 Other?
ARE YOU SURE?
 If yes- Plan the definitive treatment
 If not, at least decide the broad
categories.
 Infective or neoplastic?
 Traumatic or infective?
 Congenital or acquired?
 Localized or generalized?
Deciding to investigate
 Aims of investigation- Confirmation of
diagnostic suspicion
 Assessing the biology of the condition
 Planning the treatment
 Choose only the most relevant, simplest
investigations. (X ray?)
 Precise requisition
‘BATTERY OF INVETIGATIONS’
 Interrelated systemic disease
conditions

 Major surgical intervention being

planned

 Fussy psychic patient?

Management decision
A. When the diagnosis is clear
B. When the diagnosis is unclear
 How long to delay the decision making?

 Is it possible to pinpoint a decision in every

situation?
 Immediate or present plan of treatment

 What is your ultimate target?

Which modality to choose?
Conservative v/s operative

Basically to ‘conserve’ the function of the limb

Whichever modality restores the best of function in
optimum time frame or a combination of the two
Basics that must be MASTERED
 Thorough knowledge of the relevant
anatomy of the area
 Biology of basic inflammatory
processes as applied to the particular
area
 Consequences of scarring in the area
 Local mechanics of the bone and
concerned joint
Know the local area
 Functional demand on the area for
each patient

 decision of essential components of

function (stability v/s mobility)

 Effect of growth in case of

children(favorable/unfavorable)
Surgery or no surgery?
 ‘Knife happy’ orthopaedician

 ‘plaster happy’ orthopaedician

Middle path
When to withhold the knife?

 When the biology is tremendously in

favor of the patient.

 When the organ system and/or the

tissues will not tolerate the surgical
insult

 Tissue response is uncertain

‘Supervised negligence’ or
observation
 Minimally symptomatic, short duration ,
inconsequential problems.

 When the natural course of the condition

cannot be significantly altered by
treatment.

 Some symptomatic relief

Decision to operate
 An unfavorable biology can be made
favorable-e.g. Intra-articular fractures

 Helping the biology to run the natural

course e.g. drainage of an abscess
 Realignment of an area for cosmetic
reasons
Principle v/s the procedure
 Surgical procedure that utilizes and
reinforces the biology of the tissue
response- good results
 Procedures that depend on mechanics
alone with lesser consideration to the
biology- Questionable results
 Your own experience of tissue
behavior
Choice of procedures
 Affordability/economics of treatment

 ‘poor man’s surgeon’ v/s rich man’s

surgery

 ‘trendy surgery’
Common targets of both
modalities of treatments
 Restoration of a stable, painless,
mobile limb without deformity.
 Prevention of delayed complications
and Secondary changes
 Prevention of reactivation of the
disease process
Therapeutics in Orthopaedics
Are Orthopods bad Physicians?
Where do you need drugs?

Pain Relief
Infection prevension and control
Disease specific drugs
Sedatives
 OTHER DRUGS

Supportive therapy
 Anti osteoporotic

 Antidiabetics

 Antihypertensives

 Antitubercular

 Antihelminthics

 Calcium and Vitamin D related drugs

HOW LONG TO USE DRUGS ?
 A) For definitive therapeutics
Standard regimens of treatment in
established
doses e.g.. Anti-tubercular drugs
 B) Imperical treatment

To be used for reasonable length of time

(? 3 weeks to 3 months)
Investigative proof of effectivity
Judge the propriety of your
decision
 Periodic assessment of clinical
status of the patient is mandatory.
 Physical components of therapy like
mobilization and restoration of
function to be instituted at the right
time.
 Too long or too little immobilization
 THE PLASTER CAST

Friend and foe of the patient and the

orthopaedition both
 Friend, if you use in right size, right
pressure, right occasion for right
duration with right instructions
 Foe, if used as a cover-up of the
missing links in the surgeon’s mind or
left by itself unsupervised and
uninstructed
OTHER MODALITIES
 Traction - Skin or Skeletal ?

 Treatment - Indoor or Outdoor ?

 Observation - How long and by

Whom ?

 Orthotics - Availability and Utility ?

PHYSIOTHERAPY
 Physically REALLY active people do
not need physiotherapy - Children
 Physically inactive people require
vigorous physiotherapy - The rich
urban lot.
 Localized inactivity - following injury,
apprehensive of further damage, pain
psychology, specific purposes.
 Fitting all modalities together
The decision plan
 Utilizes combination of various
modalities in the right proportion and
right timing
 Inclusion of surgical procedure may
change the time table and the
combination of modalities
 Invasive decisions should significantly
overweigh the advantages of non
invasive treatment
TIME AS A CRITERION
 Depends on the social structure of
each area and the demands on the
patient as an individual
(International bossinessman vs.
labourer)
 ? Any intermediate time frame
available
 Go with the speed of the biology for
better reasons
Prepared for Complications ?
 All decision plans must envisage the
possible complications
 As a part of the natural disease
process, iatrogenic, drug induced,
non compliance of the patient,
superadded aetiologies, unforeseen
factors
SUMMARY
 Know your basics well and keep them
update
 Don’t try fitting a patient in to a book
chapter, use individual judgement
 Analyze the facilities, surgical
expertise, ancillary services and
related social factors.
 No hasty decisions but do not delay
unnecessarily
 Think definitive, symptomatic treatment
cannot be continued indefinitely
 Remember decisions fail even the most
experience surgeons.
TISSUE BIOLOGY IS THE
ULTIMATE DECISION MAKER,
GO WITH IT