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EditorJavad Parvizi MD FRCS
ProfessorDepartment of Orthopedic Surgery
Rothman InstituteThomas Jefferson University
Philadelphia, Pennsylvania, USA
Co-editorsWilliam J. Hozack MD
ProfessorDepartment of Orthopedic Surgery
Rothman Institute Thomas Jefferson University
Philadelphia, Pennsylvania, USA
Peter F. Sharkey MDProfessor
Department of OrthopedicsRiddle Memorial HospitalMedia, Pennsylvania, USA
Gregory K. Deirmengian MDAssociate Professor
Department of Orthopedic Surgery
Sydney Kimmel Medical CollegeThomas Jefferson University
Philadelphia, Pennsylvania, USA
New Delhi | London | Panama
The Health Sciences Publisher
Rothman Institute Manual of Total Joint
Arthroplasty Protocol-Based Care
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HeadquartersJaypee Brothers Medical Publishers (P) Ltd.4838/24, Ansari Road, DaryaganjNew Delhi 110 002, IndiaPhone: +91-11-43574357Fax: +91-11-43574314E-mail: [email protected]
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Rothman Institute Manual of Total Joint Arthroplasty: Protocol-Based CareFirst Edition: 2017ISBN: 978-93-86261-05-2Printed at:
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The views and opinions expressed in this book are solely those of the original contri butor(s)/author(s) and do not necessarily represent those of editor(s) of the book.All rights reserved. No part of this publication may be reproduced, stored or transmitted in any form or by any means, electronic, mechanical, photo copying, recording or otherwise, without the prior permission in writing of the publishers.All brand names and product names used in this book are trade names, service marks, trademarks or registered trademarks of their respective owners. The publisher is not associated with any product or vendor mentioned in this book.Medical knowledge and practice change constantly. This book is designed to provide accurate, authoritative information about the subject matter in question. However, readers are advised to check the most current information available on procedures included and check information from the manufacturer of each product to be administered, to verify the recommended dose, formula, method and duration of administration, adverse effects and contra indications. It is the responsibility of the practitioner to take all appropriate safety precautions. Neither the publisher nor the author(s)/editor(s) assume any liability for any injury and/or damage to persons or property arising from or related to use of material in this book.This book is sold on the understanding that the publisher is not engaged in providing professional medical services. If such advice or services are required, the services of a competent medical professional should be sought.Every effort has been made where necessary to contact holders of copyright to obtain permission to reproduce copyright material. If any have been inadvertently overlooked, the publisher will be pleased to make the necessary arrangements at the first opportunity.
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Jaypee Brothers Medical Publishers (P) Ltd
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Dedication Life brings us in contact with many. There are those
we will remember forever. I dedicate this to those who have made an indelible mark in my life.
Javad Parvizi
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Section Editors
Scot Brown MD
Fellow Rothman InstituteThomas Jefferson UniversityPhiladelphia, Pennsylvania, USA
Antonia F. Chen MD MBA
Assistant ProfessorRothman InstituteThomas Jefferson UniversityPhiladelphia, Pennsylvania, USA
Gregory K. Deirmengian MD
Associate ProfessorDepartment of Orthopedic SurgerySydney Kimmel Medical CollegeThomas Jefferson University Philadelphia, Pennsylvania, USA
William J. Hozack MD
ProfessorDepartment of Orthopedic SurgeryRothman Institute Thomas Jefferson UniversityPhiladelphia, Pennsylvania, USA
Paul B. McKenna MD
FellowRothman InstituteThomas Jefferson UniversityPhiladelphia, Pennsylvania, USA
Javad Parvizi MD FRCS
ProfessorDepartment of Orthopedic SurgeryRothman InstituteThomas Jefferson UniversityPhiladelphia, Pennsylvania, USA
Peter F. Sharkey MD
ProfessorDepartment of OrthopedicsRiddle Memorial HospitalMedia, Pennsylvania, USA
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Contributors
Pouya Alijanipour MD
Clinical Fellow of Spine and Pediatric Orthopedic SurgeryChildren’s Hospital of New OrleansLouisiana State UniversityNew Orleans, Louisiana, USA
Matthew S. Austin MD
Director of Joint Replacement ServicesDepartment of Orthopedic Surgery Rothman InstituteThomas Jefferson UniversityPhiladelphia, Pennsylvania, USA
Diana Bitar MD
Fellow, Department of Orthopedic Surgery Rothman InstituteThomas Jefferson UniversityPhiladelphia, Pennsylvania, USA
Scot Brown MD
Fellow, Rothman InstituteThomas Jefferson UniversityPhiladelphia, Pennsylvania, USA
Jenny Cai BS
Clinical Research CoordinatorDepartment of RadiologyUniversity of PennsylvaniaPhiladelphia, Pennsylvania, USA
David S. Casper MD
Orthopedic Surgery ResidentRothman InstituteThomas Jefferson University HospitalPhiladelphia, Pennsylvania, USA
Priscilla Ku Cavanaugh MD
Orthopedic Surgery ResidentDepartment of Orthopedic SurgeryDrexel University College of MedicineHahnemann University HospitalPhiladelphia, Pennsylvania, USA
Antonia F. Chen MD MBA
Assistant ProfessorRothman InstituteThomas Jefferson UniversityPhiladelphia, Pennsylvania, USA
Corey T. Clyde MD
Resident PhysicianDepartment of OrthopedicsUniversity at BuffaloBuffalo, New York, USA
Carl A. Deirmengian MD
Department of Orthopedic SurgeryRothman InstituteThomas Jefferson UniversityPhiladelphia, Pennsylvania, USA
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Rothman Institute Manual of Total Joint Arthroplasty: Protocol-Based Carex
Gregory K. Deirmengian MD
Associate ProfessorDepartment of Orthopedic SurgerySydney Kimmel Medical CollegeThomas Jefferson University Philadelphia, Pennsylvania, USA
Claudio Diaz-Ledezma MD
Staff Orthopedic SurgeonHospital Naval TalcahuanoTalcahuano, Chile, USA
Anthony J. DiMarino MD
Professor Thomas Jefferson University Philadelphia, Pennsylvania, USA
Edward J. Filippone MD
Clinical Associate Professor Thomas Jefferson University Philadelphia, Pennsylvania, USA
Seyedali R. Ghasemi MD
Orthopedic Research FellowRothman InstitutePhiladelphia, Pennsylvania, USA
Miguel M. Gomez MD
Research Fellow, Rothman Institute Thomas Jefferson University Philadelphia, Pennsylvania, USA
Robert P. Good MD
Clinical Associate ProfessorDepartment of Orthopedic SurgeryThomas Jefferson UniversityPhiladelphia, Pennsylvania, USA
Christina J. Gutowski MD MPH
Resident, Department of Orthopedic Surgery Thomas Jefferson University HospitalPhiladelphia, Pennsylvania, USA
Michael F. Harrer MD
Adult Reconstruction SurgeonDepartment of Orthopedic SurgeryRothman InstituteThomas Jefferson UniversityPhiladelphia, Pennsylvania, USA
Snir Heller MD
Fellow, Department of Orthopedic SurgeryRabin Medical CenterPetah Tikva, Israel
Bryan A. Hozack MD
ResidentDepartment of Orthopedic SurgeryRothman Institute Thomas Jefferson University HospitalPhiladelphia, Pennsylvania, USA
William J. Hozack MD
ProfessorDepartment of Orthopedic SurgeryRothman Institute Thomas Jefferson UniversityPhiladelphia, Pennsylvania, USA
Ronald Huang MD
Resident PhysicianDepartment of Orthopedic SurgeryThomas Jefferson University HospitalPhiladelphia, Pennsylvania, USA
H. Jane Huffnagle DO
Clinical ProfessorThomas Jefferson UniversityPhiladelphia, Pennsylvania, USA
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Suzanne Huffnagle DO
Clinical ProfessorThomas Jefferson UniversityPhiladelphia, Pennsylvania, USA
Fatih Kucukdurmaz MD
Associate ProfessorDepartment of Orthopedics and TraumatologyBezmialem Vakif UniversityIstanbul, Turkey
Eric J. Levicoff MD
Assistant Professor Sidney Kimmel Medical CollegeThomas Jefferson UniversityPhiladelphia, Pennsylvania, USA
Jess H. Lonner MD
Associate ProfessorDepartment of Orthopedic SurgeryRothman InstituteThomas Jefferson UniversityPhiladelphia, Pennsylvania, USA
Jorge Manrique MD
Fellow, Department of Orthopedic SurgeryRothman InstituteThomas Jefferson University Philadelphia, Pennsylvania, USA
Ryan Massimilla CCRP
Clinical Study ManagerRothman InstituteThomas Jefferson UniversityPhiladelphia, Pennsylvania, USA
Paul B. McKenna MD
Fellow, Rothman InstituteThomas Jefferson UniversityPhiladelphia, Pennsylvania, USA
Geno J. Merli MD
Professor Thomas Jefferson UniversityPhiladelphia, Pennsylvania, USA
Joshua J. Minori DO
Research Fellow, Department of Orthopedic ResearchRothman InstituteThomas Jefferson University HospitalPhiladelphia, Pennsylvania, USA
Philip Nimoityn MD
Clinical Assistant ProfessorDepartment of CardiologyThomas Jefferson University Philadelphia, Pennsylvania, USA
Alvin C. Ong MD
Clinical Instructor Assistant Professor Rothman InstituteThomas Jefferson University HospitalPhiladelphia, Pennsylvania, USA
Fabio Orozco MD
Associate ProfessorDepartment of Orthopedic SurgeryThomas Jefferson University Hospital Philadelphia, Pennsylvania, USA
Javad Parvizi MD FRCS
Professor, Department of Orthopedic SurgeryRothman InstituteThomas Jefferson UniversityPhiladelphia, Pennsylvania, USA
Contributors xi
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Rothman Institute Manual of Total Joint Arthroplasty: Protocol-Based Carexii
Ripal P. Patel MD
Research FellowDepartment of Orthopedic Surgery Rothman InstituteThomas Jefferson UniversityPhiladelphia, Pennsylvania, USA
Danielle Y. Ponzio MD
Resident, Department of Orthopedic SurgeryRothman Institute Thomas Jefferson University Philadelphia, Pennsylvania, USA
Zachary D. Post MD
Adult Reconstruction SurgeonRothman InstituteThomas Jefferson UniversityPhiladelphia, Pennsylvania, USA
James J. Purtill MD
Professor of Orthopedic SurgerySidney Kimmel Medical CollegeThomas Jefferson UniversityPhiladelphia, Pennsylvania, USA
Mohammad R. Rasouli MD
Resident Thomas Jefferson UniversityPhiladelphia, Pennsylvania, USA
Camilo Restrepo MD
Assistant DirectorClinical ResearchDepartment of OrthopedicsThomas Jefferson University Hospital Philadelphia, Pennsylvania, USA
Maryam Rezapoor MS
Research FellowRothman InstituteThomas Jefferson University Philadelphia, Pennsylvania, USA
Richard H. Rothman MD PhD
ProfessorDepartment of Orthopedic SurgeryThomas Jefferson University Philadelphia, Pennsylvania, USA
Eric S. Schwenk MD
Assistant Professor of AnesthesiologyThomas Jefferson UniversityPhiladelphia, Pennsylvania, USA
Alisina Shahi MD
Postdoctoral Research FellowDepartment of Clinical ResearchRothman InstituteThomas Jefferson UniversityPhiladelphia, Pennsylvania, USA
Julie L. Shaner MD
ResidentDepartment of OrthopedicsThomas Jefferson UniversityPhiladelphia, Pennsylvania, USA
Peter F. Sharkey MD
ProfessorDepartment of OrthopedicsRiddle Memorial HospitalMedia, Pennsylvania, USA
Eric B. Smith MD
Clinical Assistant ProfessorDepartment of Orthopedic SurgeryThomas Jefferson UniversityPhiladelphia, Pennsylvania, USA
Reza Mostafavi Tabatabaee MD
Joint Reconstruction FellowRothman Institute Thomas Jefferson UniversityPhiladelphia, Pennsylvania, USA
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Timothy L. Tan MD
Resident, Department of Orthopedic SurgeryThomas Jefferson UniversityPhiladelphia, Pennsylvania, USA
T. David Tarity MD
Adult Reconstruction and Joint Replacement FellowDepartment of Orthopedic SurgeryHospital for Special SurgeryNew York City, New York, USA
Lynda J. Thomson Pharm D
CACP
Advance Practice PharmacistDepartment of Pharmacy/SurgeryThomas Jefferson University HospitalPhiladelphia, Pennsylvania, USA
Eric H. Tischler BA
Research FellowRothman Institute Philadelphia, Pennsylvania, USA
Brian T. Urbani MS
Clinical Research CoordinatorDepartment of Orthopedic SurgeryRothman InstitutePhiladelphia, Pennsylvania, USA
Jessica R. Viola BS
Research Fellow, Rothman InstituteThomas Jefferson UniversityPhiladelphia, Pennsylvania, USA
Eugene R. Viscusi MD
ProfessorThomas Jefferson UniversityPhiladelphia, Pennsylvania, USA
Kristen Vogl DPT MBA
Director of Clinical ServicesAdministrator Musculoskeletal Service Line Thomas Jefferson University HospitalPhiladelphia, Pennsylvania, USA
Meng-Huang Wu MD
Attending PhysicianDepartment of Orthopedics Taipei Medical University HospitalTaipei, Taiwan
Je-Hyun Yoo MD PhD
Associate ProfessorDepartment of Orthopedic SurgeryHallym University Sacred Heart HospitalAnyang, South Korea
Benjamin Zmistowski MD
Resident Thomas Jefferson University Hospital Philadelphia, Pennsylvania, USA
Contributors xiii
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Orthopedic surgery and the delivery of care to patients have entered a new era. The financial pressure on the healthcare has compelled us to examine the cost-effectiveness of our practices and care protocols. The easy access to information on the Internet has generated well-read and fairly informed patients. The various grading systems for the doctors and the hospitals, together with the satisfaction scores from patients have all led to a rush to change the manner in which we deliver care. The recent changes in healthcare reimbursements and introduction of “bundling” in the US have further compelled the medical community to seek strategies that will allow delivery of high quality and cost-effective care. At our institution, we have been a believer in protocol-based care that allows efficient and cost-effective care. If these protocols are based on evidence, they provide further improvements in patient outcomes and serve to reduce cost. I am proud to present to you this book that summarizes many, if not all, the protocols that we have implemented at the Rothman Institute. The impetus behind writing this book is the numerous inquiries from colleagues and friends who have reached out to us asking for our protocols in various areas. We hope that having all of the institutional protocols will help our colleagues in the field to deliver greater care to their patients without having to reinvent the wheel. We realize that orthopedics is a fluid science, and many of these protocols will change in the future, if not changed by the time this book is printed. We will strive to keep the readers of this book informed of those changes by printing supplemental material in the future.
Javad Parvizi
Preface
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The completion of this book would not be possible without the immense help of many whose names do not appear in the author list. We would like to thank Katherine Huff and Krystal Golankiewicz for proofreading the chapters. Special thanks to the nurses and other residents on the ortho-pedic service who provided insight to the authors during the preparation of the chapters to ensure that the protocols were accurately presented.
Acknowledgments
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Rothman Institute Manual of Total Joint Arthroplasty: Protocol-Based Carexviii
Section 1: Preoperative Section Editors: Scot Brown, Javad Parvizi
1. Indications and Contraindications for Total Joint Arthroplasty 3Diana Bitar, James J. Purtill
2. Preoperative Radiographic Evaluation 11Camilo Restrepo, William J. Hozack
3. Consent: When and Where? 17Ryan Massimilla, Javad Parvizi
4. Perioperative Patient Evaluation 23Eric H. Tischler, Gregory K. Deirmengian
5. Additional Testing and Preoperative Consultation 27Julie L. Shaner, William J. Hozack, Philip Nimoityn
6. Management of Preoperative Medications 37Corey T. Clyde, Scot Brown
7. Prehabilitation for Total Knee Arthroplasty and Total Hip Arthroplasty 49Ripal P. Patel, Antonia F. Chen
8. Clinical Examination of the Hip 53Priscilla Ku Cavanaugh, Javad Parvizi
9. Clinical Examination of the Knee 57Priscilla Ku Cavanaugh, Javad Parvizi
Contents
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xix
10. Preoperative Nutritional Optimization 63Pouya Alijanipour, Matthew S. Austin
11. Smoking Cessation 67Pouya Alijanipour, Eric B. Smith
12. Perioperative Optimization of the Diabetic Patient 71Pouya Alijanipour, Matthew S. Austin
13. Optimization of the Patient with Cardiopathy 75T. David Tarity, James J. Purtill
14. Optimization of the Renal Failure Patient 81Timothy L. Tan, Edward J. Filippone, Antonia F. Chen
15. Optimization of Chronic Obstructive Pulmonary Disease 85T. David Tarity, James J. Purtill
16. Optimization of Sleep Apnea 89Mohammad R. Rasouli, Javad Parvizi
17. Optimization of Anemia 95Meng-Huang Wu, Javad Parvizi
18. Preadmission Testing and Preoperative Consultation 101Julie L. Shaner, William J. Hozack, Philip Nimoityn
19. Preoperative Templating 109Camilo Restrepo, Gregory K. Deirmengian
20. Implant Selection for Total Hip Arthroplasty 123Reza Mostafavi Tabatabaee, Carl A. Deirmengian
21. Implant Selection for Total Knee Arthroplasty 135T. David Tarity, Carl A. Deirmengian
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Section 2: PerioperativeSection Editors: Paul B. McKenna, Peter F. Sharkey
22. Intraoperative Deep Vein Thrombosis Prophylaxis 143Fatih Kucukdurmaz, William J. Hozack
23. Multimodal Pain Management in Total Knee Arthroplasty 147Priscilla Ku Cavanaugh, William J. Hozack
24. Multimodal Pain Management in Total Hip Arthroplasty 155Joshua J. Minori, William J. Hozack
25. Peripheral and Neuraxial Blocks for Analgesia After Total Joint Arthroplasty: Indications and Techniques 163Mohammad R. Rasouli, Eric S. Schwenk
26. Preoperative Antibiotics 173Antonia F. Chen, Javad Parvizi
27. Tranexamic Acid 179Mohammad R. Rasouli, Javad Parvizi
28. Intraoperative Steroid Administration 187Diana Bitar, Paul B. McKenna, Matthew S. Austin
29. Anesthetic Techniques in Total Joint Arthroplasty: Neuraxial Anesthesia 191Mohammad R. Rasouli, Suzanne Huffnagle, H. Jane Huffnagle
30. Anesthetic Techniques in Total Joint Arthroplasty: General Anesthesia 197Mohammad R. Rasouli, H. Jane Huffnagle, Suzanne Huffnagle
31. Skin Preparation 203Corey T. Clyde, Javad Parvizi
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32. Tourniquet Use in Total Knee Arthroplasty 209Christina J. Gutowski, Peter F. Sharkey
33. Operating Room Universal Precautions 217Pouya Alijanipour, Eric B. Smith
34. Surgical Hand Antisepsis Practices 221Danielle Y. Ponzio, Antonia F. Chen
35. Operating Room Traffic 227Eric H. Tischler, Paul B. McKenna, Matthew S. Austin
36. Draping 233Pouya Alijanipour, Richard H. Rothman
37. Approaches to the Hip: Direct Anterior 237Reza Mostafavi Tabatabaee, Paul B. McKenna, William J. Hozack
38. Approaches to the Hip: Direct Lateral 243Fatih Kucukdurmaz, Paul B. McKenna, Richard H. Rothman
39. Approaches to the Hip: Posterior 249Christina J. Gutowski, Robert P. Good
40. Medial Parapatellar Approach for Total Knee Arthroplasty 255Paul B. McKenna, Peter F. Sharkey
41. Subvastus and Midvastus Approach for Total Knee Arthroplasty 261Seyedali R. Ghasemi, Jess H. Lonner
42. Unicompartmental Knee Arthroplasty 265Je-Hyun Yoo, Jess H. Lonner
43. Patellofemoral Arthroplasty 273T. David Tarity, Jess H. Lonner
44. Total Hip Arthroplasty in Patients with Metabolic Bone Disease 279T. David Tarity, William J. Hozack
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45. Total Hip Arthroplasty in Protrusio Acetabuli 283Reza Mostafavi Tabatabaee, Matthew S. Austin
46. Total Hip Arthroplasty in Patients with Proximal Femoral Deformity 289Reza Mostafavi Tabatabaee, Matthew S. Austin
47. Total Knee Arthroplasty for Patients with Severe Deformity 295Jorge Manrique, Fabio Orozco
48. Antibiotic Impregnated Cement 303Christina J. Gutowski, Javad Parvizi
49. Computer-Assisted Total Knee Arthroplasty 309Snir Heller, William J. Hozack
50. Patient-Specific Instrumentation 313Reza Mostafavi Tabatabaee, Javad Parvizi
51. Management of Vascular Complications: Hip 317Snir Heller, Peter F. Sharkey
52. Management of Vascular Complications: Knee 321Diana Bitar, Paul B. McKenna, Peter F. Sharkey
53. Surgical Drains 331Alisina Shahi, Richard H. Rothman
54. Wound Closure 337Miguel M. Gomez, Zachary D. Post
55. Urinary Catheter in Primary Total Joint Arthroplasty 341Priscilla Ku Cavanaugh, Alvin C. Ong
56. Surgical Dressing in Total Joint Arthroplasty 345Eric H. Tischler, Peter F. Sharkey
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57. Postoperative X-rays (Hips and Knees) 349Camilo Restrepo, Alvin C. Ong
58. Heterotopic Ossification Prevention 357Camilo Restrepo, Zachary D. Post
Section 3: Postoperative ManagementSection Editors: Antonia F. Chen, Gregory K. Deirmengian
59. Operative Note Dictation in Total Joint Arthroplasty 363Claudio Diaz-Ledezma, Javad Parvizi
60. Postoperative Fluid Management 369Meng-Huang Wu, Javad Parvizi
61. Venous Thromboembolism Prophylaxis for Total Joint Arthroplasty 375Timothy L. Tan, Richard H. Rothman
62. Risk Stratification for Venous Thromboembolism After Total Joint Arthroplasty 383Maryam Rezapoor, Ronald Huang, Javad Parvizi
63. Sleeping Aids After Total Joint Arthroplasty 391Brian T. Urbani, Fabio Orozco
64. Postoperative Gastrointestinal Complications 395Danielle Y. Ponzio, Anthony J. DiMarino
65. Routine Postoperative Laboratory Investigations 401Je-Hyun Yoo, Jess H. Lonner
66. Postoperative Antibiotic Prophylaxis 405Danielle Y. Ponzio, Eric B. Smith
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67. Wound Care and Dressings 411Snir Heller, James J. Purtill
68. Transfusions 415Danielle Y. Ponzio, Javad Parvizi
69. Fever Management 421Je-Hyun Yoo, Eric J. Levicoff
70. Oxygen Desaturation Management 427Jessica R. Viola, Antonia F. Chen, William J. Hozack
71. Altered Mental Status and Postoperative Neurologic Abnormalities 433David S. Casper, Michael F. Harrer
72. Weight-Bearing After Total Joint Arthroplasty 439Diana Bitar, Peter F. Sharkey
73. Management of Urinary Retention After Total Joint Arthroplasty 445Jenny Cai, Carl A. Deirmengian
74. Management of Cardiac Arrhythmias 449Snir Heller, Philip Nimoityn
75. Management of Diagnosed Deep Vein Thrombosis 455Geno J. Merli, Lynda J. Thomson
76. Management of Diagnosed Pulmonary Embolism 465Geno J. Merli, Lynda J. Thomson
77. Physical and Occupational Therapy After Total Knee Arthroplasty 473Joshua J. Minori, Kristen Vogl
78. Physical and Occupational Therapy After Total Hip Arthroplasty 479Joshua J. Minori, Kristen Vogl
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79. Discharge Destination: Rehabilitation vs Home 485Ryan Massimilla, Kristen Vogl
80. Home Physical Therapy After Total Joint Arthroplasty 489Jorge Manrique, Kristen Vogl
81. Discharge Pain Medications 497Joshua J. Minori, Eugene R. Viscusi
82. Activity Modification After Total Hip Arthroplasty 503Reza Mostafavi Tabatabaee, Richard H. Rothman
83. Continuous Passive Motion for Rehabilitation After Total Knee Arthroplasty 509Seyedali R. Ghasemi, Richard H. Rothman
84. Follow-Up Times and Goals After Total Joint Arthroplasty 513Ryan Massimilla, Fabio Orozco
85. Antibiotic Prophylaxis for Minor Procedures After Total Joint Arthroplasty 517Fatih Kucukdurmaz, Eric J. Levicoff
86. Restarting Medications 523Corey T. Clyde, Robert P. Good
Section 4 ComplicationsSection Editors: Antonia F. Chen, William J. Hozack
87. Management of Wound Drainage After Total Joint Arthroplasty 533Alisina Shahi, James J. Purtill
88. Postoperative Blister 539Snir Heller, William J. Hozack
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89. Postoperative Infection Investigation 543Benjamin Zmistowski, Javad Parvizi
90. Management of Acute Infection: Hip 549Benjamin Zmistowski, Antonia F. Chen
91. Management of Acute Infection: Knee 553Fatih Kucukdurmaz, Antonia F. Chen, Javad Parvizi
92. Management of Chronic Infection 559Benjamin Zmistowski, Antonia F. Chen
93. Management of Dislocated Hip: Early vs Late 567Diana Bitar, William J. Hozack
94. Management of Intraoperative Fractures During Total Hip Arthroplasty 579Alisina Shahi, James J. Purtill
95. Management of Intraoperative Fractures During Total Knee Arthroplasty 583Alisina Shahi, James J. Purtill
96. Management of Postoperative Periprosthetic Hip Fractures 589Diana Bitar, Gregory K. Deirmengian
97. Management of Postoperative Periprosthetic Knee Fractures 599Julie L. Shaner, Alvin C. Ong
98. Management of the Swollen Limb in the Early Postoperative Period 607Miguel M. Gomez, Zachary D. Post
99. Management of Residual Leg Length Discrepancy After Total Hip Arthroplasty 611Bryan A. Hozack, William J. Hozack
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100. Management of Stiffness After Total Knee Arthroplasty 617Eric B. Smith, Jenny Cai
101. Management of Painful Total Knee Arthroplasty 621Benjamin Zmistowski, Peter F. Sharkey
102. Management of Neurologic Deficit: Hip 627T. David Tarity, Fabio Orozco
103. Management of Neurologic Deficit: Knee 633T. David Tarity, Fabio Orozco
Index 637
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Clinical Examination of the KneePriscilla Ku Cavanaugh, Javad Parvizi
Chapter
9
Rothman ProtocolAll patients undergo a thorough medical history and knee examination. Clinical examination of the knee consists of inspection, palpation, motor testing, neurological testing, and in certain cases determined by the clinician, other special tests. The hip is also examined to rule out hip pathology as the culprit for symptomatology.
Knee Examination AlgorithmInspectionObserve the patient walking and note the presence of a limp, asymmetry, gait or other abnormalities. Upon closer inspection, look for edema, discoloration, lacerations, scars, ecchymosis, muscle atrophy, or other abnormalities. Next, assess limb alignment with the patient standing making sure to note any genu varum, genu valgum, or genu recurvation.
PalpationBegin palpation of the knee joint by assessing its temperature, using the surrounding areas and contralateral leg for comparison. Infection or an acute knee injury may lead to a warm knee. Locate and palpate the tibial tuberosity, patella, and joint line. On both sides, palpate below the patella for swelling. Patellar subluxation should
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Rothman Institute Manual of Total Joint Arthroplasty: Protocol-Based Care58
be noted. Tenderness at the joint line may indicate intra-articular pathology such as arthritis. While moving the patient’s knee, feel for patellar tracking and crepitus. Crepitus indicates arthritis. Locate and palpate the medial and lateral meniscus noting any tenderness because it may indicate a tear. On the upper medial aspect of the tibia, locate the pes anserine bursa, palpate for any pain, effusion, or thickening. Assess stability of the collaterals by stabilizing the distal femur and applying varus and valgus stress to the tibia at full extension and with the knee flexed to 20°. Stability of the menisci and cruciates are tested by specific examinations (discussed in Table 9.3).
Motor AssessmentEvaluate the patient’s active and passive range of motion (Table 9.1).
Neurocirculatory AssessmentAssessment includes a pertinent vascular examination followed by sensory, muscle, and reflex testing.
Vascular ExaminationBegin with the patient’s knee relaxed in flexion, palpate for the popliteal pulse located deep behind the knee. Next, distally palpate the dorsalis pedis and posterior tibialis
Table 9.1. Range of motion assessment (ROM) components for the knee
Knee Exam Patient PositioningNormal
ROM up to
Internal/external rotation
Seated, femur stabilized, tibia rotated
10°
Flexion Supine, knee bent, heel towards buttocks
135°
Extension Supine, straighten knee from bent position
0°
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Clinical Examination of the Knee 59
bilaterally for strength and symmetry. Note that absence of hair or skin discoloration may signify poor circulation.2 If abnormalities are found and peripheral vascular disease (PVD) is suspected, ankle-brachial indexes (ABI) should be obtained using Doppler ultrasound. It is crucial to identify PVD patients, because PVD is a relative contraindication to total knee arthroplasty. An ABI of 0.9–1.3 is considered normal; if less than 0.9, the patient may have elevated risk of arterial complications and should be referred to a vascular surgeon. An ABI less than 0.5 indicates severe ischemia and an angiogram is recommended.3
Sensation TestingTest sensation in dermatomal distribution and assess the different sensory modalities: temperature, sharp touch, light touch, vibration, and proprioception.
Muscle TestingBilaterally assess power of muscle groups, using the contralateral limb for comparison. Maneuvers are shown in Table 9.2.
Reflex TestingBoth the patellar reflex (L2, 3, 4) and ankle reflex (S1) should be assessed bilaterally.
Other Common/Special TestsAdditional individual knee components are tested with other specific tests. Maneuvers for key tests are described in Table 9.3.
Table 9.2. Muscle examination components for the knee
Exam Muscles Involved
Extension Primary: quadriceps femoris
Flexion Primary: Hamstring muscles (biceps femoris, semitendinosus, semimembranosus)
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Rothman Institute Manual of Total Joint Arthroplasty: Protocol-Based Care60
Tabl
e 9.
3. K
nee
exam
inat
ion
test
s
Exam
Man
euve
rsPo
siti
ve T
est
Inte
rpre
tati
on
App
rehe
nsio
n te
st
for p
atel
lar i
nsta
bilit
y an
d su
blux
atio
n
(a) S
eate
d pa
tient
sup
port
s lo
wer
le
g, p
lace
you
r thu
mb
on la
tera
l fe
mor
al e
pico
ndyl
e as
you
la
tera
lly p
ush
the
med
ial s
ide
of
pate
lla(b
) Sea
ted
patie
nt, fl
exes
and
ex
tend
s kn
ee
(a) P
atel
la s
ublu
xatio
n(b
) Inv
erte
d J-
shap
ed
mot
ion
of p
atel
la
Pate
llar i
nsta
bilit
y
Med
ial c
olla
tera
l lig
amen
t (M
CL)
Supi
ne p
atie
nt, s
ecur
e th
e an
kle
and
push
med
ially
aga
inst
kne
e an
d la
tera
lly a
gain
st ip
sila
tera
l ank
le
Gap
in m
edia
l bor
der o
f kn
ee jo
int;
pain
MCL
dam
age
Late
ral c
olla
tera
l lig
amen
t (LC
L)Su
pine
pat
ient
, sec
ure
the
ankl
e an
d pu
sh la
tera
lly a
gain
st k
nee
and
med
ially
aga
inst
ipsi
late
ral a
nkle
Pain
LCL
dam
age
Dra
wer
test
Supi
ne p
atie
nt w
ith k
nee
90° fl
exed
, sl
ide
prox
imal
tibi
a an
terio
rly (a
) or
post
erio
rly (b
); co
mpa
re to
uni
njur
ed
knee
(a) A
nter
ior t
rans
latio
n(b
) Pos
terio
r tra
nsla
tion
(a) A
CL in
jury
(b) P
CL in
jury
*Not
e: In
tegr
ity o
f AC
L no
t pre
serv
ed
durin
g TK
A
Jayp
ee B
rothe
rs
Clinical Examination of the Knee 61
Lach
man
Supi
ne p
atie
nt w
ith k
nee
flexe
d 20
°–30
°, an
terio
r for
ce a
pplie
d to
pr
oxim
al ti
bia
Laxi
ty o
f tib
ia, t
ibia
pu
lled
forw
ard
ACL
defic
ienc
y
Pivo
t shi
ft
Supi
ne p
atie
nt, k
nee
exte
nded
, IR,
ap
ply
valg
us fo
rce
and
flex
knee
Late
ral t
ibia
l pla
teau
sh
ifts
post
erio
rlyAC
L de
ficie
ncy
McM
urra
y Su
pine
pat
ient
, flex
ed h
ip a
nd k
nee,
pa
lpat
e la
tera
l joi
nt s
pace
, and
with
ot
her h
and
alte
rnat
e be
twee
n IR
and
ER
of f
oot
Pain
(with
men
isca
l sn
ap o
r cre
pitu
s)M
edia
l or l
ater
al
men
isca
l tea
r/le
sion
Squa
t tes
tSq
uats
by
patie
nt, f
eet a
nd le
gs
alte
rnat
ing
betw
een
inte
rnal
and
ex
tern
al ro
tatio
n fo
r eac
h sq
uat
(a) M
edia
l pai
n(b
) Lat
eral
pai
n(a
) Lat
eral
men
isca
l te
ar(b
) Med
ial m
enis
cal
tear
Jayp
ee B
rothe
rs
Rothman Institute Manual of Total Joint Arthroplasty: Protocol-Based Care62
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immediate preoperative vascular examination in an at-risk patient for total knee arthroplasty. Orthopaedics. 2011;34(1):52.
3. Tria AJ Jr. Clinical examination of the knee. In: Scott WN, editor. Insall & Scott surgery of the knee. 4th ed. Philadelphia, PA: Churchill Livingstone Elsevier; 2006; pp. 86–9.
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Jayp
ee B
rothe
rs