Dustin Briggs, MD Credit to Chris Hanosh, MD Adult Reconstruction UNM Department of Orthopaedics

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