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, polymethyl- methacrylate (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”