Consultant Orthopedic Surgery oral assessment prep

Knowledge: This is an acute postoperative periprosthetic joint infection until proven otherwise, and persistent wound drainage beyond five to seven days is itself a marker of infection, not a benign finding. I would use a formal definition such as the European Bone and Joint Infection Society or the 2018 International Consensus Meeting criteria rather than an impression, combining serum markers, synovial fluid analysis, microbiology and histology.

Management: I would admit him, withhold antibiotics until samples are taken, and perform an aseptic knee aspiration sending fluid for cell count and differential, Gram stain, culture and, where available, alpha-defensin. I would take blood cultures, check inflammatory markers serially, review the operative and microbiology record, and involve infectious diseases early.

Ethics and communication: Infection after arthroplasty is emotionally devastating for patients, and my duty is to be honest early rather than to minimise it as a superficial wound problem.

Reference: EBJIS Definition of Periprosthetic Joint Infection, Bone and Joint Journal, 2021; and Proceedings of the International Consensus Meeting on Musculoskeletal Infection, 2018

Knowledge: Wrong-level spinal surgery is classified as a never event, meaning a serious, largely preventable patient safety incident that should not occur when available preventive measures are implemented. The particular vulnerability of the spine is that the surgical site is not visible externally, adjacent levels look identical, and anatomical variants such as a transitional lumbosacral vertebra, sacralisation, lumbarisation or six lumbar vertebrae make counting unreliable if performed on a single view or without reference to the preoperative MRI.

Management: My first advice would be to stop the dissection, take a formal intraoperative localising radiograph or fluoroscopic image with a marker in the wound and count from the sacrum, comparing directly with the preoperative MRI displayed on the theatre screen, and to get a second surgeon and, if available, a radiologist to confirm the level independently.

Ethics and communication: The patient must be told, fully and promptly, by the operating surgeon with a senior colleague present, once she is awake and able to understand. She should be told what happened, that the intended level was subsequently decompressed correctly, what the potential consequences are, that we are sorry, and what will be done to investigate and to prevent recurrence, and she should be given a written summary and a named contact.

Reference: WHO Surgical Safety Checklist and Guidelines for Safe Surgery, World Health Organization, 2009; and North American Spine Society, Sign, Mark and X-ray (SMaX) Prevention of Wrong-Site Spine Surgery Protocol

Knowledge: This is acute compartment syndrome until proven otherwise, and the most important thing I would say to the panel is that escalating analgesic requirement that outstrips what the injury and the block should produce is the single most useful early warning sign. A warm foot, a palpable pulse and moving toes are entirely compatible with an established compartment syndrome, because the syndrome is a failure of microcirculatory perfusion at tissue level, not of arterial inflow, and pulselessness and paralysis are late and pre-terminal signs.

Management: I would attend the patient immediately in person rather than manage this by telephone. I would split all circumferential dressings down to skin, return the limb to the level of the heart, stop or reduce the block infusion so serial clinical assessment becomes meaningful, correct hypotension and give oxygen and fluids to maximise perfusion pressure, and reassess personally within minutes.

Ethics and communication: This is a complication that will attract scrutiny, so my professional obligation is to be transparent with the patient and his family from the outset: I would explain in plain language what compartment syndrome is, why an urgent second operation is needed, that the wounds will be left open, and what the potential consequences of delay are, using an interpreter if required.

Reference: BOAST: Diagnosis and Management of Compartment Syndrome of the Limbs, British Orthopaedic Association, 2016

Knowledge: There are three intertwined problems here: a surgical decision, an antithrombotic decision, and a consent and capacity decision, and I would address them separately rather than letting the family dynamic drive the clinical plan. Surgically, a displaced intracapsular fracture in this age group will not reliably heal with internal fixation, so the choice is between hemiarthroplasty and total hip arthroplasty.

Management: I would admit her under a shared orthogeriatric model, assess and document capacity formally, and aim for surgery on the next available list within 36 hours. Preoperatively I would take a full delirium screen, correct dehydration and anaemia, screen for the cause of the fall including postural hypotension and medication review, provide a fascia iliaca or femoral nerve block for analgesia to reduce opioid use and delirium, and avoid prolonged fasting.

Ethics and communication: The ethical centre of this case is that neither the patient's dissent nor the son's demand is determinative. I would carry out and document a structured capacity assessment covering understanding, retention, weighing and communication, and record that she lacks capacity for this decision while still involving her, explaining things simply and repeatedly, and honouring her preferences where they do not conflict with her best interests.

Reference: NICE CG124 Hip Fracture: Management, updated 2023; and AAOS Clinical Practice Guideline, Management of Hip Fractures in Older Adults, 2021