dustin briggs, md credit to chris hanosh, md adult reconstruction unm department of orthopaedics
TRANSCRIPT
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Dustin Briggs, MD
Credit to Chris Hanosh, MD
Adult Reconstruction
UNM Department of Orthopaedics
Surgical Management of Hip and Knee Arthritis
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Diagnosis made with weightbearing radiographs
MRI used sparingly (not required for referral!)Arthroscopy extremely limited roleArthroplasty intended to relieve painModifiable risk factors addressed pre-
operativelyIdentify predictors of poor arthroplasty
outcomesPost-op diagnosis: “Arthroplasty disease”
TAKE HOME POINTS
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Radiographic Diagnosis:Knee:At least 3 weightbearing views: AP, lateral,
MerchantAdd Rosenberg for early arthritis“Sports series” in UNM system
HipAP pelvis, 2 views of affected hip: AP, lateral
Look for the “4 S’s”
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Radiographic Diagnosis:The 4 S’s
Joint Space narrowingSubchondral sclerosisBone Spurs (terrible name!!!)
Osteophytes Subchondral cysts
Body’s response to arthritisProcess toward “auto-fusion”
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Radiographic Diagnosis:
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Radiographic Diagnosis:The “Rosenberg”
Discovered during arthroscopy“Kissing lesion” of most severe OA
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Knee Alignment:
Fixed versus passively correctableThese patients present differently.
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Radiographic Diagnosis:
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Radiographic Diagnosis:
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Normal or near-normal weightbearing radiographsGet the Rosenberg
before the MRI!
MRI not required for evaluation for hip or knee replacement!
Evaluate preservation of other “compartments”
Indications for MRI
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Almost none!Should we clean out meniscal tears?
NoShould we shave down cartilage?
NoCAVEATS to the above
Acute onset of painful mechanical symptoms
Role of Arthoscopy in Arthritis
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InjectionsCortisone, “viscosupplementation”
Assistive deviceCane, walker
BracingNeoprene sleeve, hinges, unloader
MedicationsNSAIDs, tramadol, narcotics, G/C
Physical therapy, conditioning
“Exhaust” conservative management
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Intermittently dispersed will be the boring (but important) stuff
We are so close to surgery pictures!
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TKA and THATwo of the most predictably successful surgical
procedures in all of medicine
Total knee “replacement” is a bit of a misnomer:“Resurfacing” more appropriate than
“replacement”
Total hip replacement:Truly is a “replacement” procedure
Total Joint Arthroplasty:
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61 yo M, longstanding h/o pain, severely limited ROM
Very advanced arthritisThe “4’s”Near autofusion
Exam is important!Limited ROM
No internal rotation
Severe hip osteoarthritis
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Hip OA
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Total hip arthroplasty (replacement)
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DislocationPosterior hip precautions
Limb length inequalityGoal within 1 cm
Peri-prosthetic fractureIntra-op versus post-op
DVT/PELovenox versus Aspirin
Infection24-hours post-op ABX
Pre-op counseling: Complications
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Total hip arthroplasty
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Total hip arthroplasty
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Total hip arthroplasty
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Normal Knee
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Normal Knee
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“Trim away cartilage containing portion of bone”
Measured resection
Cobalt-chrome, titanium, polyethylene, polymethyl-methacrylate (PMMA)
Total Knee Arthroplasty (resurfacing):
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Before and after…
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Lateral view…
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Merchant view…
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Young ageHigh activity level/expectations
The 3 G’s (golf, gardening, and grandkids)Not a “new knee”
Minimal radiographic findings“MRI diagnosis of OA”
Use of narcotics pre-op
Candidate for “partial” knee replacement?
Predictors of Poor Outcome TKA
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ObesityDiabetes MellitusSmokingMalnutritionMRSAPoor DentitionOther InfectionsSocial Environment
Modifiable Risk Factors
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Wound complicationsInfectionMalpositioned implantsUnintended injuryIncreased operative timeIncreased failure rate of implants
Obesity
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HA1c<7
Perioperative glycemic controlWound healingInfection
Philosophy versus Fact
Diabetes Mellitus
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Optimal time prior to surgery is 6 monthsBenefits shown as soon as 6 weeksELECTIVE PROCEDUREPhilosophy versus Fact
Smoking
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Serum Albumin < 3.5g/dLTransferrin < 226mg/dLTotal lymphocyte count < 1500/mm^3Wound healing Infection
Malnutrition
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Risk factorsHospital employeeICU stayHistory of MRSAFamily member with history of MRSA
Preop AbxVanco and Ancef
MRSA
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No active dental issuesGet routine work done prior to surgery
Dental Evaluation
UTISkinToenails
Other Infection Sources
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How we doing on time?
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Medial unicompartmental arthroplastyIsolated medial compartment arthritis
Patellofemoral arthroplastyIsolated patellofemoral arthritis
Less invasive, quicker recovery, more “natural” knee
Bimodal distributionYoung and active
“bridging” procedure?Elderly
progressive disease less likely
“Partial” knee replacements
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Longstanding medial left knee painMultiple previous physicians
“Too young”“Normal x-rays”
Finally established with a “Sports” partnerMRI revealed cartilage delaminationAttempted microfracture
Continued pain and disability“Exhausted” conservative management
Case example, 54 yo M
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Standing AP & Rosenberg
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MRI Coronal & Sagittal (T2)
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Medial UKA
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Remote history of patella fractureHealed with “fibrous non-union”Isolated anterior knee pain
Prolonged sittingStairs, inclines/declinesGiving way episodes
MRI reveals well-preserved M/L compartments
Case example, 53 yo F
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Post-traumatic patellofemoral OA
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Well preserved M/L compartments
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Patellofemoral arthroplasty
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2-hour surgery2-nights inpatient2-weeks of acute surgical pain
“gets worse before better”severe painnarcotic medicationsassistive devices incision healing
2-months better than pre-opreturn to work
The Rule of 2’s
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Antibiotics for 24 hoursDVT prophylaxisPain controlRehabilitation
Post Operative
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Range of MotionGait TrainingStrengtheningWound CareEdema Control
The “forgotten hip”
Rehabilitation
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We don’t know!Highly cross-linked polyethyleneThe “30-year knee”Revision rate 1% per year, cumulative
Longevity
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Requires management for lifetime of patient
“Arthroplasty disease”InfectionPeri-prosthetic fractureImplant failureDislocation
A Total Joint is Forever
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Diagnosis made with weightbearing radiographs
MRI used sparingly (not required for referral!)Arthroscopy extremely limited roleArthroplasty intended to relieve painModifiable risk factors addressed pre-
operativelyIdentify predictors of poor arthroplasty
outcomesPost-op diagnosis: “Arthroplasty disease”
TAKE HOME POINTS
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Thank You