dustin briggs, md credit to chris hanosh, md adult reconstruction unm department of orthopaedics
TRANSCRIPT
Dustin Briggs, MD
Credit to Chris Hanosh, MD
Adult Reconstruction
UNM Department of Orthopaedics
Surgical Management of Hip and Knee Arthritis
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
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”
Radiographic Diagnosis:The 4 S’s
Joint Space narrowingSubchondral sclerosisBone Spurs (terrible name!!!)
Osteophytes Subchondral cysts
Body’s response to arthritisProcess toward “auto-fusion”
Radiographic Diagnosis:
Radiographic Diagnosis:The “Rosenberg”
Discovered during arthroscopy“Kissing lesion” of most severe OA
Knee Alignment:
Fixed versus passively correctableThese patients present differently.
Radiographic Diagnosis:
Radiographic Diagnosis:
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
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
InjectionsCortisone, “viscosupplementation”
Assistive deviceCane, walker
BracingNeoprene sleeve, hinges, unloader
MedicationsNSAIDs, tramadol, narcotics, G/C
Physical therapy, conditioning
“Exhaust” conservative management
Intermittently dispersed will be the boring (but important) stuff
We are so close to surgery pictures!
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:
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
Hip OA
Total hip arthroplasty (replacement)
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
Total hip arthroplasty
Total hip arthroplasty
Total hip arthroplasty
Normal Knee
Normal Knee
“Trim away cartilage containing portion of bone”
Measured resection
Cobalt-chrome, titanium, polyethylene, polymethyl-methacrylate (PMMA)
Total Knee Arthroplasty (resurfacing):
Before and after…
Lateral view…
Merchant view…
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
ObesityDiabetes MellitusSmokingMalnutritionMRSAPoor DentitionOther InfectionsSocial Environment
Modifiable Risk Factors
Wound complicationsInfectionMalpositioned implantsUnintended injuryIncreased operative timeIncreased failure rate of implants
Obesity
HA1c<7
Perioperative glycemic controlWound healingInfection
Philosophy versus Fact
Diabetes Mellitus
Optimal time prior to surgery is 6 monthsBenefits shown as soon as 6 weeksELECTIVE PROCEDUREPhilosophy versus Fact
Smoking
Serum Albumin < 3.5g/dLTransferrin < 226mg/dLTotal lymphocyte count < 1500/mm^3Wound healing Infection
Malnutrition
Risk factorsHospital employeeICU stayHistory of MRSAFamily member with history of MRSA
Preop AbxVanco and Ancef
MRSA
No active dental issuesGet routine work done prior to surgery
Dental Evaluation
UTISkinToenails
Other Infection Sources
How we doing on time?
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
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
Standing AP & Rosenberg
MRI Coronal & Sagittal (T2)
Medial UKA
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
Post-traumatic patellofemoral OA
Well preserved M/L compartments
Patellofemoral arthroplasty
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
Antibiotics for 24 hoursDVT prophylaxisPain controlRehabilitation
Post Operative
Range of MotionGait TrainingStrengtheningWound CareEdema Control
The “forgotten hip”
Rehabilitation
We don’t know!Highly cross-linked polyethyleneThe “30-year knee”Revision rate 1% per year, cumulative
Longevity
Requires management for lifetime of patient
“Arthroplasty disease”InfectionPeri-prosthetic fractureImplant failureDislocation
A Total Joint is Forever
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
Thank You