Transcript Surgical Management of Knee Arthritis

Dustin Briggs, MD
Credit to Chris Hanosh, MD
Adult Reconstruction
UNM Department of Orthopaedics
 Diagnosis made with weightbearing radiographs
 MRI used sparingly (not required for referral!)
 Arthroscopy extremely limited role
 Arthroplasty intended to relieve pain
 Modifiable risk factors addressed pre-operatively
 Identify predictors of poor arthroplasty outcomes
 Post-op diagnosis: “Arthroplasty disease”
 Knee:
 At least 3 weightbearing views: AP, lateral, Merchant
 Add Rosenberg for early arthritis
 “Sports series” in UNM system
 Hip
 AP pelvis, 2 views of affected hip: AP, lateral
 Look for the “4 S’s”
 The 4 S’s
 Joint Space narrowing
 Subchondral sclerosis
 Bone Spurs (terrible name!!!)
 Osteophytes
 Subchondral cysts
 Body’s response to arthritis
 Process toward “auto-fusion”
 Discovered during arthroscopy
 “Kissing lesion” of most severe OA
 Fixed versus passively correctable
 These patients present differently.
 Normal or near-normal
weightbearing radiographs
 Get the Rosenberg
before the MRI!
 MRI not required for evaluation
for hip or knee replacement!
 Evaluate preservation of other
“compartments”
 Almost none!
 Should we clean out meniscal tears?
 No
 Should we shave down cartilage?
 No
 CAVEATS to the above
 Acute onset of painful mechanical symptoms
 Injections
 Cortisone, “viscosupplementation”
 Assistive device
 Cane, walker
 Bracing
 Neoprene sleeve, hinges, unloader
 Medications
 NSAIDs, tramadol, narcotics, G/C
 Physical therapy, conditioning
 Intermittently
dispersed will be the
boring (but important)
stuff
 TKA and THA
 Two 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
 61 yo M, longstanding h/o
pain, severely limited ROM
 Very advanced arthritis
 The “4’s”
 Near autofusion
 Exam is important!
 Limited ROM
 No internal rotation
 Dislocation
 Posterior hip precautions
 Limb length inequality
 Goal within 1 cm
 Peri-prosthetic fracture
 Intra-op versus post-op
 DVT/PE
 Lovenox versus Aspirin
 Infection
 24-hours post-op ABX
 “Trim away
cartilage containing
portion of bone”
 Measured resection
 Cobalt-chrome,
titanium,
polyethylene,
polymethylmethacrylate
(PMMA)
 Young age
 High 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?
 Obesity
 Diabetes Mellitus
 Smoking
 Malnutrition
 MRSA
 Poor Dentition
 Other Infections
 Social Environment
 Wound complications
 Infection
 Malpositioned implants
 Unintended injury
 Increased operative time
 Increased failure rate of implants
 HA1c
 <7
 Perioperative glycemic control
 Wound healing
 Infection
 Philosophy versus Fact
 Optimal time prior to surgery is 6 months
 Benefits shown as soon as 6 weeks
 ELECTIVE PROCEDURE
 Philosophy versus Fact
 Serum Albumin < 3.5g/dL
 Transferrin < 226mg/dL
 Total lymphocyte count < 1500/mm^3
 Wound healing
 Infection
 Risk factors
 Hospital employee
 ICU stay
 History of MRSA
 Family member with history of MRSA
 Preop Abx
 Vanco and Ancef
 No active dental issues
 Get routine work done prior to surgery
 UTI
 Skin
 Toenails
 Medial unicompartmental arthroplasty
 Isolated medial compartment arthritis
 Patellofemoral arthroplasty
 Isolated patellofemoral arthritis
 Less invasive, quicker recovery, more “natural” knee
 Bimodal distribution
 Young and active
 “bridging” procedure?
 Elderly
 progressive disease less likely
 Longstanding medial left knee pain
 Multiple previous physicians
 “Too young”
 “Normal x-rays”
 Finally established with a “Sports” partner
 MRI revealed cartilage delamination
 Attempted microfracture
 Continued pain and disability
 “Exhausted” conservative management
 Remote history of patella fracture
 Healed with “fibrous non-union”
 Isolated anterior knee pain
 Prolonged sitting
 Stairs, inclines/declines
 Giving way episodes
 MRI reveals well-preserved M/L compartments
 2-hour surgery
 2-nights inpatient
 2-weeks of acute surgical pain
 “gets worse before better”
 severe pain
 narcotic medications
 assistive devices
 incision healing
 2-months better than pre-op
 return to work
 Antibiotics for 24 hours
 DVT prophylaxis
 Pain control
 Rehabilitation
 Range of Motion
 Gait Training
 Strengthening
 Wound Care
 Edema Control
 The “forgotten hip”
 We don’t know!
 Highly cross-linked polyethylene
 The “30-year knee”
 Revision rate 1% per year, cumulative
 Requires management for lifetime of patient
 “Arthroplasty disease”
 Infection
 Peri-prosthetic fracture
 Implant failure
 Dislocation
 Diagnosis made with weightbearing radiographs
 MRI used sparingly (not required for referral!)
 Arthroscopy extremely limited role
 Arthroplasty intended to relieve pain
 Modifiable risk factors addressed pre-operatively
 Identify predictors of poor arthroplasty outcomes
 Post-op diagnosis: “Arthroplasty disease”