Explore every episode of the podcast Total Knee Tips & Pearls From Dr. Adam Rosen (A Virtual Total Knee Fellowship Podcast)
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Title
Pub. Date
Duration
Uni's
10 Jun 2022
00:13:27
I am going to cover some of the things I consider when approaching Uni's
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This is an important episode because we are all at risk. If you are in trouble or suffering ask for help, get help, seek help and ask for help again. If you see a colleague or friend who is having trouble ask how you can help and be sure to check in with them or seek help from your attending or other supervisors.
Here I discuss some of the things I look for when seeing patients in the office when I am deciding on what treatment options are appropriate. Weight bearing x-rays are important. Ask patients to describe their symptoms. Do not simply ask someone to describe their pain on a scale of one to ten. Find out how their knee has affected their quality of life. Lastly, find out what treatment options have been tried and be sure to offer conservative treatment options to the patient before undergoing surgery.
My name is Adam Rosen. I am an orthopedic surgeon in Southern California. I did my residency in Philadelphia and fellowship in La Jolla. I have been in practice since 2005 performing total knee replacements. I am part of a teaching fellowship program and I try to share my thought process with our fellows. I am going to share my thought process here in an attempt to help you and potentially the patients that you care for.
This podcast series is really geared towards orthopedic residents or fellows or the community surgeon looking to pick up a pearl or two about total knee replacements. I do not believe that my way is the best way or the only way to care for patients with knee arthritis. I only offer my thoughts, opinions and treatment algorithms in the hopes that it will help you care for your patients. This is my opinion. You need to determine how to treat your own patients based on your experience, education and available scientific data.
I am happy to share my new book THE KNEE BOOK - A GUIDE TO THE AGING KNEE
It was written for patients and it is written to patients in easy to understand language.
The book is a perfect recommendation for patients with knee pain that have questions.
I believe it is also a great resource for residents and young surgeons. In it I review the algorithm for treating patients with knee pain from the most conservative up to knee replacement.
What I think is the best benefit for young surgeons is all of the analogies I use to explain things to my patients. You can pick these up by reading the book so that you can better explain things to your patients.
It is also a great read for non-orthopedic doctors, PA's or NP's. Anyone that treats knee pain patients. It explains why we need weight bearing x-rays and not MRI's and more.
I still do this every Friday (sooner if it is a complicated revision) Check the patient, age, BMI, nasal swab, dvt proph. Check the x-rays and make sure the implants are ordered. Review the labs and any clearances that are needed.
Double check everything necessary with the patient the day of surgery.
Make sure the room is set up with everything you need prior to the patient coming into the room.
Whether you are doing a hemi or total, cementing the femoral component takes some skill. Here I will share with you my tips on how to get a good cement mantle.
I discussed varus knees previously, here is my two cents on what I look for and how I approach the valgus deformity when performing a TKA
Krackow I - min valgus II - deformity > 10 degree, medial soft tissue stretching III - severe, incompetent medial soft tissues, have constrained/hinge avail
I had the chance to sit down for the second time with Dr. Colwell. In this episode we cover teaching fellows, running two rooms, bilateral total joints and more.
If you haven't listen to the first episode you can listen here:
Know if it is fixed or correctable Assess the amount of osteophytes Release MCL around to semimembranous Assess PCL if using CR Consider downsizing tibial and removing additional medial bone
Further Reading:
Master Techniques Knee Arthroplasty - Lotke and Lonner Chapter 7 by Scuderi and Insall
Advanced Reconstruction of the Knee AAOS Chapter 27 - Varus Knee - Windsor and Choi
I first met Dr. Colwell when I came west to interview for a fellowship at Scripps Clinic. I had the pleasure to sit down and ask him some questions about orthopedics and his career. We talked for an hour and a half and I could have spent all day listening to his stories. We didn't have time to get to every question that I had for him so I hope we can sit down again soon for a second Dr. Colwell interview.
& so much more A bi-monthly podcast where we share the stories of our Caregivers, patients and...
References: Ng et al. Preoperative Risk Stratification and Risk Reduction for Total Joint Reconstruction. AAOS 2013 Aram et al. Estimating an Individual's Probability of Revision Surgery After Knee Replacement. Am J of Epid 2018 Gronbeck et at. Risk stratification in primary total joint arthroplasty. Arthroplasty Today 2019 Florschutz et al. Estimating patient specific mortality after joint replacement. Osteoarthritis and Cartilage 2019 Ziebma-Davis et al. Outpatient Joint Arthroplasty. J Arthoplasty 2019 National Joint Registry online Risk Assessment tool. jointcalc.shef.ac.uk
Smallest - Zimmer 1 Narrow (55.5 mm M/L, 48.1 mm AP) Biggest - Aesculap F8 (82 MM M/L, 80.5 mm AP)
Lots of stuff! Check with your reps and always refer to the technique manual, this is just a brief review but does not take the place of training and education.
& so much more A bi-monthly podcast where we share the stories of our Caregivers, patients and...
I find this topic a more difficult topic to teach than knee balancing. Everything is important to get a stable hip. You need a good approach, pre-op planning, implant positioning and the restoration of length and offset. You need to be aware of balancing and how to address anatomic on anatomic impingement, implant on anatomic and implant on implant impingement.
These two tips can be used when performing a hemiarthroplasty for a hip fracture. You may also consider it even if doing a THA for a fracture or a THA for arthritis in certain patients such as parkinson's disease.
Its good to have an algorithm that works for you when describing an x-ray. Here I will go through my thought process to make sure that you cover everything and not miss things.
The kinematics of the knee are so complex. You can not overlook the PFJ. We are taught early on about medializing the button and lateralize the femur and make sure your femoral rotation is correct. If not you are taught to do a lateral release.
The balancing of the PFJ is so important. Overstuff it and you have pain and limited range of motion. Too loose and you lose efficiency of the extensor mechanism.
Here I will share some tips and my thoughts on what I look for when I do a TKA specifically focusing on the PFJ.
Roentgenographic Analysis of Patellofemoral Congruence
Alan Merchant, Richard Mercer, Richard Jacobsen, Charles Cool
JBJS 1974
Merchant View - patient is supine on the x-ray table. The knees are flexed 45 degrees and the legs are strapped. The beam to femur angle is 30 degrees and the plate is positioned against the shins.
Sulcus Angle of Brattstrom - angle formed by the highest points on the medial and lateral femoral condyles and the lowest point of the sulcus
Congruence Angle - sulcus angle is bisected to establish the reference line. Another line is drawn from the apex of the sulcus to the lowest point on the patellar articular surface.
The Forty-five-Degree Posteroanterior Flexion Weight-Bearing Radiograph of the Knee
Thomas Rosenberg, Lonnie Paulos, Richard Parker, David Coward, Steven Scott
JBJS 1988
PA x-ray with the knee in 45 degrees of flexion and the patella touching the cassette. The beam is aimed at the inferior pole of the patella and aimed 10 degrees caudad,
55 patients in 1981-1982 (age 19-70)
Major narrowing in the medial compartment AP xray - 25% Rosenberg - 85% Major narrowing in the lateral compartment AP xray - 30% Rosenberg - 80%
Additional advantage of identifying osteophytes in the notch, loose bodies, OCD and SONK
Current Concepts Review Impingement with Total Hip Replacement JBJB 2007 Aamer Malik, MD, Aditya Maheshwari, MD, and Lawrence Dorr, MD
For hip stability: Evaluate the x-rays and template Be wary of hypermobile patients and spine patients Know your implants (head options, neck options, etc) Check patients supine and again lateral (for posterior approach) Meticulous approach Proper reaming and cup placement and remove osteophytes Proper broaching and remove osteophytes
Check Ranawat sign 1. 45 degrees for females 2. 20 - 30 degrees for males
How I test stability 1. leg length 2. capsular tension and palpate offset 3. extension and rectus tension 4. extension and external rotation 5. position of sleep 6. full flexion in neutral 7. 90 degrees, slight adduction and internal rotation 8. assess intraoperative x-rays Then make changes based on stability.
& so much more A bi-monthly podcast where we share the stories of our Caregivers, patients and...
Hopefully your system does not go down but when it does here is your cheat sheet.
1. ALWAYS DATE AND TIME 2. SIGN and print your name and/or doctor number, pager number, etc 3. Make sure the patients name and medical record number or DOB is on the page
A- Admit D - Diagnosis C - Condition and Code Status V - Vitals A - Allergies A - Activity N- Nursing D - Diet I - IVF M - Medications L - Labs and Tests S - Special - PT, OT, Case Management
And DATE AND TIME IT
Common Meds after TKA - always check the medication, dose and frequency and the safety profile for the patient. Abx - Ancef 1 gm q8 (occ Vanco or other) VTE Prevention - Asa 81 mg BID (or 325mg or eliquis, xarelto, warfarin, enoxaparin, etc) Scheduled Pain Meds 1. acetaminophen 1000 mg PO q8 2. celebrex 200 mg PO BID 3. sometimes: gabapentin 100 mg PO q8 Breakthru Pain Meds 1. Tramadol 50 mg PO q6 prn mild pain (level 1-5) 2. Oxycodone IR 5 mg PO q6 prn moderate pain (level 6-9) 3. Oxycodone IR 10 mg PO q6 prn severe pain (level 10) 4. sometimes: IV breakthru medications Bowel - colace 100 mg PO BID GI - pepcid 20 mg PO BID Puritis - claritin 10 mg PO q day prn itching Nausea - zofran 4 mg IV q 6 prn nausea HOME MEDS! if diabetic don't forget sliding scale insulin
Two studies have shown that essential amino acids (EAA) can help function, and suppress atrophy of the rectus after TKA.
Dreyer et al. J Clinc Invest. 2013;123(11):4654-4666. Essential amino acid supplementation in patients following total knee arthroplasty.
Ueyama et al. The Bone & Joint Journal Vol 102-B, No. 6, Supp A. Perioperative essential amino acid supplementation suppresses rectus femoris muscle atrophy and accelerates early functional recovery following total knee arthroplasty.
The two brands I recommend to patients are Thorne ( https://amzn.to/3KPuC2i ) and Pure Encapsulations ( https://amzn.to/3ObJj1U )
Changes in Trabecular Pattern of the Upper End of the Femur as an Index of Osteoporosis Manmohan Singh et al JBJS 1970
Grade 6 - All normal trabeculae are visible Grade 5 - accentuation of the principal compressive and principal tensile trabeculae - Ward's triangle looks empty Grade 4 - tensile trabeculae are reduced - Ward's triangle opens up laterally - border line between osteoporotic and normal bone Grade 3 - break in the continuity of the priciple tensile group - definite osteoporosis Grade 2 - principal compressive trabeculae are the only prominent trabeculae Grade 1 - all trabeculae are reduced
The Normal Trabecular Pattern 1. Principal compressive group 2. Secondary compressive group 3. Greater trochanter group 4. Principal tensile group 5. Secondary tensile group
Wards Triangle (first described 1838) An area in the neck between the principal compressive, secondary compressive and primary tensile group
The International Consensus Meeting on MSK Infection presented their new criteria in 2018
Major Criteria 1. Two positive periprosthetic cultures w/ phenotypically identical organisms 2. A sinus tract communicating with the joint ____________________ Minor Criteria > or equal to 6 = infected 4-5 = inconclusive < or equal to 3 = not infected ___________________ 2 points for: Serum CRP 100 in acute or 10 in chronic or D-dimer 860 in chronic
1 point for: ESR 30 in chronic
3 points for: synovial WBC 10,000 in acute or 3,000 in chronic or leuk esterase ++ in acute and ++ in chronic or positive alpha defensin 2 points for: synovial PMN 90 in acute or 70 in chronic
Kellgren, Lawrence. Radiological Assessment of Osteoarthritis. Ann Rheum Dis. 1957;16:494-502
Grade 0 - No presence of OA Grade 1 - Doubtful narrowing, possible osteophytes Grade 2 - Possible narrowing, definite osteophytes Grade 3 - Definite narrowing, moderate osteophytes, some sclerosis and possible deformity Grade 4 - severe narrowing, large osteophytes, marked sclerosis, definite deformity
X-rays finding of OA narrowing of joint space osteophytes sclerosis of subchondral bone pseudocystic changes altered shape
Type I - minimal metaphyseal bone loss Type II - extensive metaphyseal bone loss, minimal diaphyseal bone loss Type IIIA - extensive metaphyseal and diaphyseal bone loss with greater or equal to 4 cm intact diaphysis for "scratch fit" Type IIIB - extensive metaphyseal and diaphyseal bone loss with less than 4 cm of intact diaphysis Type IV - extensive metaphyseal and diaphyseal bone loss with a non-supportive isthmus
Treatments I - cylindrical fully porous coated stem (consider tapered proximal geometry or cemented stem) II - diaphyseal engaging stem IIIA - diaphyseal engaging stem (impaction grafting, modular stems) IIIB - tapered stem with splines for rotational stability (impaction grafting, modular stems, PFR) IV - PFR, impaction grafting with cemented stem, allografts
Aribindi, Barba, Solomon, Arp, Paprosky. Bypass fixation. Orthop Clin North AM. 1998;29:319. Paprosky, Aribindi. Hip Replacement: treatment of femoral bone loss using distal bypass fixation. ICL 2000;49:119-130. Della Valle, Paprosky. The femur in revision total hip arthroplasty evaluation and classification. CORR 2004;420:55-62. Cross, Paprosky. Managing femoral bone loss in revision total hip replacement: fluted tapered modular stems. Bone Joint J. 2013;95 (11 supp A):95-97.
I just wanted to share my thoughts and give you my two cents on where we may be in ten years. We still have 20% of patients that are dissatisfied after TKA. WHY? We get answers from industry - nav and robots? But, what is the question? Listen in to hear my thoughts on AR and AI and how a heads up display could help you decide how to best perform a TKA to get satisfaction rates up to 95% or higher.
Low-Angle Fixation in Fractures of the Femoral Neck Garden JBJS-B 1961
Stage I - Incomplete and abducted or valgus impacted Stage II - Complete and non-displaced Stage III - Complete partially displaced Stage IV - Complete fully displaced
Pauwels Classification 1935
I - up to 30 degrees II - 30 - 50 degrees III - greater than 50 degrees
a line drawn thru the fracture on the AP x-ray in relation to a line from the horizontal
Bonus credit - look up Wards Triangle first described in 1838
Type 1 - Minimal bone defect, intact metaphysis - Treat with cement or impaction grafting
Type 2A - Metaphyseal bone damage of 1 femoral condyle (F2A) or 1 half of the tibial plateau (T2A); posterior condyles are reduced - Treat with cement, augments, bone graft, cones/sleeves
Type 2B - Metaphyseal bone damage of bone femoral condyles (F2B) or both sides of the plateau (T2B) - Treat with cement, augments, bone graft, cones/sleeves
Type 3 - Massive bone loss of large portion of the condyles and/or plateaus; can involve the collaterals and/or patellar tendon - Treat with allograft, custom implants, sleeves/cones/augments, hinge, DFR
A Classification of Bone Defects, In: Revision Knee Arthroplasty. 1997 p 63-120
Engh and Ammeen 1. Classification and Pre-operative Radiographic Evaluation. Ortho Clinics N. Amer 1998 Apr; 29(2) 205-17. 2. Classification and Alternative for Reconstruction. ICL 1999, 48: 167-175.
Here I review the two common classifications for ON of the hip, Ficat and Steinberg.
The modified Ficat, Idiopathic bone necrosis of the femoral head, was published in 1985 JBJS-Br
0 - Preclinical and pre-radiographic I - Xray is normal but hip is symptomatic II - sclerosis and cysts on xray III - Crescent sign IV - OA with a deformed head
Steinberg, A quantitative system for staging avascular necrosis, JBJS-Br 1995
0 - Normal 1 - Xray normal, BS +, MRI + 2 - sclerosis and cysts on x-ray 3 - crescent sign 4 - flattening of the femoral head 5 - joint space narrowed without acetabular involvement 6 - advanced DJD
for stages 1 - 5 he further describes volume of involvement mild <15% moderate 15% - 30% severe > 30%
Knee Joint Changes after Meniscectomy by T.J. Fairbank published JBJS - Br 1948
The following radiological changes were seen after meniscectomy 1. Ridge formation 2. Narrowing of the joint space 3. Flattening of the femoral condyle
Class I - Islands of bone within the soft tissue around the hip Class II - Bone spurs from the pelvis or proximal femur , leaving at least 1 cm between Class III - Bone spurs from the pelvis or proximal femur, reducing the space between to less than 1 cm Class IV - bony ankylosis
Although rarely seen with newer TKA designs this was a diagnosis seen in patients with TKAs and could be extremely symptomatic.
Patellar clunk was first described by Hozack et al in 1989.
Patellar clunk occurred when a fibrous nodule forms above the patella. This nodule would get caught in the intercondylar notch in flexion and then cause a painful clunk as patients whet from flexion into extension.
This is a clinical diagnosis.
Patients tend to do well with arthroscopic debridement when there are no radiologic abnormalities such as loosening or malposistion.
This is the first in a series of episodes where I review some classic articles and classifications.
The Outerbridge classification was first presented in JBJS-B in 1961
The classification is as follows: 1 - Softening and swelling 2 - Fragmentation and fissuring less than 1/2 inch diameter 3 - Fragmentation and fissuring greater than 1/2 inch diameter 4 - exposed bone
In my first year of practice I remember a day where I only had three joints but it took all day and I was exhausted. Although they were all primaries they each had a component that made them hard - size, bone loss, stiffness.
I created a system that allowed me to communicate with my scheduler so they could spread out the hard cases which prevented one day from having all chip shot easy cases and another day which had all of the hard cases.
I hope you find this tip helpful in your practice.
Most gunners, interns and residents have memorized "the chart." That chart with what to do in a TKA when flexion is loose or the extension gap is tight or vice versa. Here I want to review that and more and discuss the things that I look for during balancing.
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Ortho is consulted for many things. Here I would like to go over a few topics.
First, for most ortho consults we need an x-ray. For a fracture or dislocation it is imperative. Even without trauma a bone can break if it had an un-diagnosed tumor. Even when the xray is normal, the information is important.
I will discuss compartment syndrome, cellulitis, dog bites, and more. I also cover some classic knee jerk reactions in post-operative patients such as when to and when not to pan-culture and order CT's and US.
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Here I share with some some tips and tricks on what I look for and what I do when caring for the 50 and older patient with knee pain that does not have severe arthritis and does have a meniscus tear.
I also share some tips on what to do during boards collections to make sure you have copies of the intra-op photos and how I discuss the surgical findings with my patients in the office.
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Hip fractures are a frequent admission at hospitals. Here I will go over things that are helpful in getting patients to the OR safely and timely.
It is not important for the medical team to attempt to classify the type of fracture, leave that up to the orthopedic team. Simply refer to it as a right or left hip fracture. Occasionally, the ER or radiologist is wrong and all you do is propagate the mistake in the medical record.
Blood loss, VTE, prophylaxis, pain management as well as discharge planning is discussed.
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I hate the word clearance, but prefer a pre-op eval or stratification.
Here I will go into detail of the things I look for when a patient is referred to their PCP prior to elective orthopedic surgery. I will go over not only what, by why each item is important. For each test I will explain what peri-operative complications could occur and why we may want to correct certain things prior to surgery.
& so much more A bi-monthly podcast where we share the stories of our Caregivers, patients and...