Total Knee Tips & Pearls From Dr. Adam Rosen (A Virtual Total Knee Fellowship Podcast)

Here I go into how I describe to a patient what a total knee replacement is by using a total knee model.  I make it a habit to not only detail all of the potential risks of the surgery but I go into detail when certain risks are higher in an individual patient (such as infection risk in a diabetic).  Explaining realistic expectations up front is extremely important in my opinion to create good patient satisfaction after total knee replacement surgery.  I review with my patients normal expectations such as warmth, night pain, lateral numbness and clicking that can be seen in the early post-operative period.Support the show (https://www.patreon/TotalKneeTips)

I want to review the things that I look for in the pre-operative workup to help optimize patients in an effort to reduce the chance of a complication.  I will discuss clearances, social habits like tobacco use and alcohol consumption, lab tests and nasal swabs.  It is also important in my opinion to ask about prior anesthesia complications and potential allergies or reactions to materials that may be used during surgery.  You need to think about prior incisions, retained hardware and consider if you need special implants for added constraint based on a patients exam.Support the show (https://www.patreon/TotalKneeTips)

I review what I double check the day before: labs, deformity, X-rays, implants and other things such as MRSA status, pacemakers or DBS.  In the room I review my set up including the bed, lights, tourniquet and leg positioner.  Review the plan with anesthesia regarding pain management.  And sign your surgical site!Support the show (https://www.patreon/TotalKneeTips)

In this episode we get into the OR and start the surgery.  It all begins with the TIME OUT. I review my approach and tips on marking the arthrotomy.  I work in a circular fashion - medial release followed by superior followed by lateral and will review what I do and why.  The removal of osteophytes at this point are important in my mind to increase exposure and decrease the risk of marginal fractures when using the saw later.Support the show (https://www.patreon/TotalKneeTips)

The PFJ and its kinematics are quite complex.  When dealing with the patella during TKA you have many options on how to prepare the patella.  Here I will discuss some of the options and go into detail how I expose and prepare the patella.Support the show (https://www.patreon/TotalKneeTips)

Here I will review my steps for the femur.  The debate between CR and PS is as old as the debate between which came first - the chicken or the egg.  The variables you control are the distal cut, the rotation, the sizing and more.Support the show (https://www.patreon/TotalKneeTips)

In this episode I will go over how I expose and prepare the tibia cut.  I will go over things to be aware of such as the tibial slope, rotation, cut thickness and tips on how to accurately pin your block and cut the tibia.Support the show (https://www.patreon/TotalKneeTips)

Balancing a TKA is a long and complex topic.  It is also an art.  Individual biology can play a role.  I will review some tips on what I look for when balancing a knee.  The discussion will include both bony resections and soft tissue releases.  I will also cover some areas where you may inadvertently affect the balancing while implanting the TKA.Support the show (https://www.patreon/TotalKneeTips)

Cementing is an art.  The cement can be affected by the room temperature, humidity or how it is mixed.  When you apply PMMA you want to be sure that the bone surface is dry.  As you apply your implants you want to be sure not to alter the bone preparation or alignment, especially in osteoporotic bone.https://twitter.com/dradamrosenhttps://WWW.DRADAMROSEN.COMSupport the show (https://www.patreon/TotalKneeTips)

Finishing up the TKA the closure is extremely important.  I will review how I close and tips on what to watch out for to help get a "water tight seal."  I will also share my post-operative photo that I believe helps patients get motivated and obtain good flexion.Support the show (https://www.patreon/TotalKneeTips)

I believe that these are all important so I wanted to re-review some important operative tips.  I will review ways that you could potentially alter the alignment during the procedure.  We will also go over ways to control the saw and decrease potential contamination and infection.  Lastly, I will go over ways to be more efficient.  Remember: slow is smooth and smooth is fast.  Having a plan, working with teams and being purposeful can make you a more efficient surgeon.Support the show (https://www.patreon/TotalKneeTips)

Here I will give you a full audio walk thru of a typical TKA from draping to closure.  Although previous episodes have gone into more detail of each individual part of the operation, this episode will take you through the procedure with a focus on knee position and retractor position from start to finish.  This should hopefully build on what you have listened to in previous episodes.Again, I do not believe that this is the best or only way to do a TKA but it is a step-wise pattern that works well for me.Support the show (https://www.patreon/TotalKneeTips)

Pain control following a total knee is an art and a science.  The idea of multimodal non-narcotic scheduled medication is a great improvement over the old way of treating pain.  Here I will review my philosophy and algorithm for treating pain symptoms related to total knee replacement surgery.Support the show (https://www.patreon/TotalKneeTips)

The surgery is just one part of obtaining a good total knee outcome.  The patient and their participation in post-operative PT is just as important to obtain a good outcome.  A good total knee needs good range of motion and strength that will result in a well functioning total knee.  Here I will discuss some of the tips I have used with my patients, and the reasons behind them, which have resulted in good outcomes and good range of motion.Support the show (https://www.patreon/TotalKneeTips)

Stiffness after TKA can be a big problem.  The goal is to not develop stiffness and this begins with preoperative education, a technically well done TKA and appropriate post-op PT.  Still, some patients may get stiff.  Your goal is to capture those patients early so that there is still time to make a difference.  Otherwise a MUA may be needed.  Here I will share things that I have seen and tips that I have used to keep my rate of stiffness and need for MUA low.Support the show (https://www.patreon/TotalKneeTips)

In training we focus on the procedure.  Unfortunately, some do not get enough exposure with the post-operative patient care issues.  Here I will discuss some common things I see, how I educate my patients and what things to watch out for at both the one month and three month follow-up appointments.Support the show (https://www.patreon/TotalKneeTips)

I have had the idea of creating a podcast for quite some time and it has been a really interesting learning experience for me. I am grateful for all of the listeners and subscribers.  My hope has always been to share my thoughts and tips in an attempt to give you one tip or tool that allows you to help one patient obtain a better outcome.In this last episode of Season one I just wanted to review briefly what we have talked about but reiterate some important pearls.  My plan for season two is to talk about revisions, the workup of the painful total knee, infections, periprosthetic fractures and more.Once again, thanks for listening and stay safe.Support the show (https://www.patreon/TotalKneeTips)

Restoring the joint line is the most important part of a total knee revision in my opinion.  Restoring the JL in any total knee is important but it is most difficult to re-create in a revision due to the bone loss.  Here I review my experiences and tips on what I do to restore the JL to the appropriate position.https://www.DrAdamRosen.comSupport the show (https://www.patreon/TotalKneeTips)

Patients present with painful total knees and the diagnosis is not always easy.  Here I will talk about what I do in my workup of these patients.  I go back to before surgery and get early xrays and listen to what conservative treatments they have had.  A detailed peri-operative history and any complications is important.  Labs, aspirations and special tests all have a role.  The differential is large and you have to have a good plan an algorithm to go through all of the potential causes of pain.Support the show (https://www.patreon/TotalKneeTips)

The dreaded hip dislocation is a complication we all want to avoid.  Balancing is very important.  Here I discuss my steps for checking stability in every patient every time.1. leg length2. combined Ranawat sign3. Extension4. Extension and external rotation5. Position of sleep6. Full flexion7. Flexion, adduction and internal rotationThis sequence helps me look for osteophytes that can be a source of impingement and instability.  It allows me to determine if I need to make a change in the cup position, stem position, offset or length.https://www.DrAdamRosen.comSupport the show (https://www.patreon/TotalKneeTips)

The acetabulum is the part that I find many young surgeons have the least experience with.  In residency they become comfortable with the approach and the femur but get little exposure to the cup.  Here I try to share with you some of the key tips for doing the cup well.  Exposure is key.  Recognizing the real hip center is important.  Reaming well is an art that is dependent on the patient anatomy and the depth of the cup.  Cup implantation occurs with a crescendo decrescendo technique to be sure that you are down, that you can hear that the cup is seated and a way to prevent iatrogenic fractures.Support the show (https://www.patreon/TotalKneeTips)

In keeping with the hip theme here I talk about my approach to the femoral preparation in total hip replacement.  As always exposure is key.  Opening the femur and initial broaching is important to keep you out of varus.  Be artful in broaching to prevent causing an iatrogenic fracture.Support the show (https://www.patreon/TotalKneeTips)

I am a posterior guy.  Here I will try to walk you through some of the anatomy and offer my tips on what I do and how I do the posterior approach.  Being aware of the tension of the soft tissue on the way in can help you with your balancing during the case. I have a meticulous approach to the release of the piriformis and the capsulotomy.Support the show (https://www.patreon/TotalKneeTips)

It may not sound glorifying but I recommend you talk to your scrub tech and see if you can step in for a case and be the tech.  I used to have younger residents scrub the case for a DHS or IMHS.  At the time they didn't appreciate it but later on realized how much it helped them.I believe that when you step into their shoes you will understand how difficult that job can be and it will also help your surgical skills.  During the case you may only be thinking one step ahead.  But if you are the scrub you need to be thinking three or four steps ahead.Try it.Support the show (https://www.patreon/TotalKneeTips)

I came from Philadelphia where I only saw PS knees.  I was told CR knees were hard to expose and hard to balance.  When I went west for my fellowship I saw predominantly CR knees.  In practice I perform CR knees for 95% of my primary TKAs.  I will share with you some of my thoughts and tips.Support the show (https://www.patreon/TotalKneeTips)

TKA patients may develop a DVT or PE.  Patients are either at normal risk of developing a clot or higher than normal risk.  You should be aware of and have read the Academy guideline as well as Chest guidelines.  Here I will touch on VTE after TKA and the multimodal approach as well as the variability in normal risk patients and high risk individuals.Support the show (https://www.patreon/TotalKneeTips)

Patient education is so important.  Here I review what I do with my patients on morning rounds.  You can educated them on pain control, VTE prevention, wound care and the prevention of constipation.It is so important that you ask permission to expose the patient to evaluate their wound. More often than not doctors throw back the sheets or lift up someones gown to expose them.  The intention was to care for the patient but you should ask permission and let them know what you plan to do.What is most important in my opinion is reviewing range of motion exercises, specifically extension and flexion exercises. I sit down and go over the steps of two of these exercises with each of my patients every morning on rounds and I think the benefit for them is so valuable to obtaining a good outcome.Support the show (https://www.patreon/TotalKneeTips)

I see many people struggle using the saw.  Having good hand and 3D spatial perception helps.  I find those that have built houses, cars, boats and other things have an advantage.  But everyone can learn to get better.  Watch surgeons that have good technique and watch how they hold the saw, where they hold their saw and how they brace their hands.  When you cut, cut on the guide, feel the saw, listen to the saw and look at the saw blade.  Many time the sound should let you know when your hand deviate from position.  Looking at where the saw blade is worn will let you know which direction you are torquing the saw and/or your hands.  Practice makes perfect so keep thinking, watching and practicing.  Over time you will develop the muscle memory you need.Support the show (https://www.patreon/TotalKneeTips)

Distal Femoral Replacements are commonly used for tumors but more frequently for periprosthetic fractures.  Here I will go over some of my tips for the next time you have one of these cases.  It is important to note the length of the limb - prior to removing the distal femur.  I review my landmarks for accurately restoring rotation.  You will commonly see hyperextension and I will discuss why you should avoid chasing it with a thicker poly.  And how I treat these patients postoperatively.Support the show (https://www.patreon/TotalKneeTips)

When you start practicing your salary will be much higher than what you were making in residency.  It is easy to spend, but the money may not always last.  Be smart and save and here I will offer some advice I was given early on in my career.It is important to protect yourself and your family.  When you are young and healthy, you are in the best place to purchase insurance.  As you age you are more likely to have health conditions which will make obtaining insurance more expensive.Although life insurance is important if you die, there is the possibility that something will happen to you which will prevent you from being able to work.  You want to protect yourself and your family by adequately covering your most important asset - you!Support the show (https://www.patreon/TotalKneeTips)

Simple - use TXA.  Transfusion rates used to be high.  Patients routinely auto-donated.  We also used medications to prevent VTE which increased the risk of bleeding.  The use of TXA has lowered transfusion rates significantly and has become a standard for total knee replacement surgery.Support the show (https://www.patreon/TotalKneeTips)

Revisions are hard.  They may be for one component or all components.  It may be for laxity, stiffness, poly wear, aseptic loosening, infection or fracture.  In any event they can be difficult.Here I will talk through my approach to the exposure and how I remove the femoral and tibial components.In the next episode I will go into bone cuts, sizing, rotation and the joint line.Support the show (https://www.patreon/TotalKneeTips)

Everything is a series of steps.  Once you have performed the approach and the implant removal it is time to prepare the bone.You can do this in many ways. I typically start with the tibia then move to the femur.  Performing the distal femur and tibia cut and knowing my extension gap helps me size and position the femur.  Knowing what size component and the size of the augments and potentially the need to offset helps balance the flexion gap with the extension gap.Support the show (https://www.patreon/TotalKneeTips)

Balancing is important whether or not you are doing a primary or a revision.  Restoring the joint line is key.  From that point you need to balance your extension and flexion gaps.  Although a primary TKA the main variables are soft tissue releases or bone cuts, in a revision you have those options but more commonly you will use implant size, augments and offset to restore balancing.  Rotation is another important factor, especially in fixed bearing knees.  I balance initially with a CR to get a "feel" of the knee.  I then balance with a stabilized insert to identify the appropriate rotation of the tibia while the post is engaged with the femoral component.Support the show (https://www.patreon/TotalKneeTips)

In training many people are not exposed to the wounds in the early post-op period.  Your experience may be limited to dressing changes in the hospital.  Over the years my wound closure has evolved.  Here is will talk about my experience with staples, dermabond and Prineo.  I will go over how I deal with patients who are "spitting a stitch." Most importantly I recommend having your patients come in when they are having wound issues.  Many times you can address something early before it becomes a big problem.Support the show (https://www.patreon/TotalKneeTips)

The patient experience is important, especially when you are starting out and working on building your practice.  Patients tell their friends and that will be a way to steer more patients to you office.  When you schedule a surgery that is a very tangible thing for patients and they will happy with the plan.More often than not we evaluate and give advice and offer some treatment plan.  Although there is a lot of information in the spoken word patients may leave overwhelmed or forget key aspects of what you said. They may have people ask what the doctor did for them and their response may be "nothing, it was a waste of time."Take the time to create very detailed patient forms.  I have forms for exercise, OTC meds, weight loss, post injection instructions and more.  This way the patient leaves with the information but it is also written and available for them to review.  This should lead to better compliance and a happier patient.Here is a link to my website with some of my most common forms:https://www.rosenhipandknee.com/patient-forms-orthopedic-surgeon-sandiego.htmlSupport the show (https://www.patreon/TotalKneeTips)

Knee pain may be due to the hip.  In a normal knee, mildly arthritic knee or TKA think about the hip - specifically the abductors.  With a weak medius, the femur and knee may rotate inwards, which can lead to pain.  Her I discuss some tips on the exam and what I recommend to my patients if I diagnose abductor weakness.Support the show (https://www.patreon/TotalKneeTips)

Pes planus can have an effect on TKA's.  Be sure to examine the whole leg when evaluating patients.Be sure to check out the article by Meding et al in JBJS Aug 2005 on The planovalgus foot.Support the show (https://www.patreon/TotalKneeTips)

Living in San Diego summer is stingray season.  If you train or work or travel to ocean environments it is good to be aware of potential injuries that can occur. To prevent disturbing a stingray it is recommended to do the stingray shuffle.  If they do sting you immersing the body part in hot water typically denatures the protein and stops the burn.  Rarely, an xray will show a retained barb.  Jellyfish, depending on the type and location, can be treated with removal of the tentacle and vinegar in certain instances.  Other injuries and cuts and abrasions are at risk of pretty nasty infections due to the bacteria found in the ocean such as Vibrio.  Be sure to use the appropriate broad spectrum antibiotics to cover all of the bad potential pathogens.Interested in a wilderness medicine course on other medical emergencies and treatment, check out https://wilderness-medicine.com/Support the show (https://www.patreon/TotalKneeTips)

When there is a severely comminuted fracture of the distal femur in an older individual one usually considers a DFR.  When the tibial plateau fractures we typically think either conservative care or ORIF.  Occasionally patients may benefit from a TKA.  This does require some special care to allow the tissue envelope to heal, to allow some early bone consolidation and to be able to comfortably use augments and other revision TKA components.  I encourage you to search up studies and familiarize yourself with this topic so that you can consider it next time you see a patient with this injury pattern.Support the show (https://www.patreon/TotalKneeTips)

Being in practice for 15 years has allowed me to see and be involved in many improvements in patient care.  Here I will outline ten things that have evolved to improve outcomes.  In addition they have helped control cost, which is beneficial to the health care system.Support the show (https://www.patreon/TotalKneeTips)

I am not a coding expert.  I know that through med school, residency and fellowship I received little to no education on coding.  Here I want to offer my simple overview of new versus established, level 3 vs level 4 and how to code based on time.  I hope this offers an introduction and helps you dig further by asking questions and possibly taking a coding course.Support the show (https://www.patreon/TotalKneeTips)

TKA's are complicated and the femoral preparation is complicated.  We are concerned about bone resection, rotation, sizing and more.  If the implant is wide or gaps tight you may need to downsize.  The initial referencing can be anterior or posterior.  Each has its pro's and con's.  Here I will try my best to explain the basic similarities and differences of anterior and posterior referencing.Support the show (https://www.patreon/TotalKneeTips)

It looks like things will be virtual for now.  I am going to offer my thoughts on what I was looking for when I applied for a fellowship.  I'll review things I think are important such as number and type of cases, office hours and education.  Briefly, I touch on things I discuss as an overview of the fellowship I am involved in.  Disclaimer: I work where I did my fellowship so there may be some bias.Support the show (https://www.patreon/TotalKneeTips)

In season 3 I am going to try to pass on some orthopedic knowledge to non-orthopedic health care providers.It has been shown that the MSK knowledge coming out of medical school is poor, yet a high number of visits in the office and ER are for orthopedic problems.Here I am starting with non-traumatic knee pain in patients over 50.  I will attempt to cover other common presenting diagnoses in future episodes.The recommended xrays:1. Standing (Weight Bearing) AP2. Rosenberg view (Standing flexed knee PA)3. Lateral4. Merchant or sunrise view of the patellaThe AAOS Knee exercise guide:https://orthoinfo.aaos.org/globalassets/pdfs/2017-rehab_knee.pdfSupport the show (https://www.patreon/TotalKneeTips)

Here I will review the 3 common achilles problems - achilles tendinitis, achilles tendinosis and achilles tendon rupture.  I will discuss the plantaris tendon rupture which can be mistaken for an achilles injury.I will briefly describe the symptoms, exam and workup for these diagnoses.I will explain why MRI's are not needed for the diagnosis of an achilles tendon rupture - the have been shown to be a waste of time and money and can delay care.Support the show (https://www.patreon/TotalKneeTips)

Here I am going to try to go through hip pain in the office setting in patients over 50.  Think about location, is it in the groin, laterally or in the buttock.  Take a good history and physical exam.  Xray are beneficial but need to be WEIGHT BEARING to adequately assess for arthritis.  Although MRI are useful for tumors, infections and osteonecrosis or fractures not seen on xray, the MRI is not as helpful in older individuals for certain diagnoses.  Most patients over 50 and almost all with arthritis have labral tears so an MRI is not necessary for those patients - wastes resources.Lateral hip pain syndrome can include ITB syndrome, bursitis and tendinitis.  Buttock pain and radiculopathy can be from the back in individuals who have back disease.Support the show (https://www.patreon/TotalKneeTips)

I hate the word clearance, but prefer a pre-op eval or stratification.Here I will go into detail of the things I look for when a patient is referred to their PCP prior to elective orthopedic surgery.  I will go over not only what, by why each item is important.  For each test I will explain what peri-operative complications could occur and why we may want to correct certain things prior to surgery.Support the show (https://www.patreon/TotalKneeTips)

Hip fractures are a frequent admission at hospitals.  Here I will go over things that are helpful in getting patients to the OR safely and timely.It is not important for the medical team to attempt to classify the type of fracture, leave that up to the orthopedic team.  Simply refer to it as a right or left hip fracture.  Occasionally, the ER or radiologist is wrong and all you do is propagate the mistake in the medical record.Blood loss, VTE, prophylaxis, pain management as well as discharge planning is discussed.Support the show (https://www.patreon/TotalKneeTips)

Ortho is consulted for many things.  Here I would like to go over a few topics.First, for most ortho consults we need an x-ray.  For a fracture or dislocation it is imperative.  Even without trauma a bone can break if it had an un-diagnosed tumor.  Even when the xray is normal, the information is important.I will discuss compartment syndrome, cellulitis, dog bites, and more.  I also cover some classic knee jerk reactions in post-operative patients such as when to and when not to pan-culture and order CT's and US.Support the show (https://www.patreon/TotalKneeTips)

Most gunners, interns and residents have memorized "the chart."  That chart with what to do in a TKA when flexion is loose or the extension gap is tight or vice versa.  Here I want to review that and more and discuss the things that I look for during balancing.Support the show (https://www.patreon/TotalKneeTips)

In my first year of practice I remember a day where I only had three joints but it took all day and I was exhausted.  Although they were all primaries they each had a component that made them hard - size, bone loss, stiffness.I created a system that allowed me to communicate with my scheduler so they could spread out the hard cases which prevented one day from having all chip shot easy cases and another day which had all of the hard cases.I hope you find this tip helpful in your practice.Support the show (https://www.patreon/TotalKneeTips)

This is the first in a series of episodes where I review some classic articles and classifications.The Outerbridge classification was first presented in JBJS-B in 1961The classification is as follows:1 - Softening and swelling2 - Fragmentation and fissuring less than 1/2 inch diameter3 - Fragmentation and fissuring greater than 1/2 inch diameter4 - exposed boneSupport the show (https://www.patreon/TotalKneeTips)

Although rarely seen with newer TKA designs this was a diagnosis seen in patients with TKAs and could be extremely symptomatic.Patellar clunk was first described by Hozack et al in 1989.Patellar clunk occurred when a fibrous nodule forms above the patella.  This nodule would get caught in the intercondylar notch in flexion and then cause a painful clunk as patients whet from flexion into extension.This is a clinical diagnosis.Patients tend to do well with arthroscopic debridement when there are no radiologic abnormalities such as loosening or malposistion.Support the show (https://www.patreon/TotalKneeTips)

Brooker et al JBJS Vol 55-A 1973Class I - Islands of bone within the soft tissue around the hipClass II - Bone spurs from the pelvis or proximal femur , leaving at least 1 cm betweenClass III - Bone spurs from the pelvis or proximal femur, reducing the space between to less than 1 cmClass IV - bony ankylosisSupport the show (https://www.patreon/TotalKneeTips)

Knee Joint Changes after Meniscectomy by T.J. Fairbankpublished JBJS - Br 1948The following radiological changes were seen after meniscectomy1. Ridge formation2. Narrowing of the joint space3. Flattening of the femoral condyleSupport the show (https://www.patreon/TotalKneeTips)

Here I review the two common classifications for ON of the hip, Ficat and Steinberg.The modified Ficat, Idiopathic bone necrosis of the femoral head,  was published in 1985 JBJS-Br0 - Preclinical and pre-radiographicI - Xray is normal but hip is symptomaticII - sclerosis and cysts on xrayIII - Crescent signIV - OA with a deformed headSteinberg, A quantitative system for staging avascular necrosis, JBJS-Br 19950 - Normal1 - Xray normal, BS +, MRI +2 - sclerosis and cysts on x-ray3 - crescent sign4 - flattening of the femoral head5 - joint space narrowed without acetabular involvement6 - advanced DJDfor stages 1 - 5 he further describes volume of involvementmild 30%Support the show (https://www.patreon/TotalKneeTips)

Vancouver Classification by Duncan and Masri ICL 1995Treatment options added in CORR 2004Type AAL - lesser trochanter - non-op unless larger medial pieceAG - greater trochanter - non-op unless >2.5 cm displacementType BB1 - well fixed stem - ORIFB2 - loose stem, adequate bone stock - revision w/ ORIFB3 - loose stem poor bone stock - revision w/ allograft or PFRType CC - fracture below the tip of the stem - ORIFSupport the show (https://www.patreon/TotalKneeTips)

Barrack & Harris JBJS-Br 1992"Improved Cementing Techniques and Femoral Component Loosening in Young Patients with Hip Arthroplasty. A 12 Year Radiographic Review."A - Complete fill, the classic "White Out"B - slight radiolucencyC - radiolucencies 50% - 99%D - complete radiolucent line 100% and/or failure to cement the tip of the stemSupport the show (https://www.patreon/TotalKneeTips)

Dorr Classification; Bone 1993"Structural and Cellular Assessment of Bone Quality of Proximal Femur"A - Thick cortex - champagne flute canalB - Thin cortex with residual funnel shapeC - Thin cortex - "stove pipe canal"Canal/Canal RatioA - 0.75Support the show (https://www.patreon/TotalKneeTips)

AORI ClassificationType 1 - Minimal bone defect, intact metaphysis     - Treat with cement or impaction graftingType 2A - Metaphyseal bone damage of 1 femoral condyle (F2A) or 1 half of the tibial plateau (T2A); posterior condyles are reduced     - Treat with cement, augments, bone graft, cones/sleevesType 2B - Metaphyseal bone damage of bone femoral condyles (F2B) or both sides of the plateau (T2B)     - Treat with cement, augments, bone graft, cones/sleevesType 3 - Massive bone loss of large portion of the condyles and/or plateaus; can involve the collaterals and/or patellar tendon     - Treat with allograft, custom implants, sleeves/cones/augments, hinge, DFRA Classification of Bone Defects, In: Revision Knee Arthroplasty. 1997 p 63-120Engh and Ammeen1. Classification and Pre-operative Radiographic Evaluation. Ortho Clinics N. Amer 1998 Apr; 29(2) 205-17.2. Classification and Alternative for Reconstruction. ICL 1999, 48: 167-175.Support the show (https://www.patreon/TotalKneeTips)

Low-Angle Fixation in Fractures of the Femoral NeckGarden JBJS-B 1961Stage I - Incomplete and abducted or valgus impactedStage II - Complete and non-displacedStage III - Complete partially displacedStage IV - Complete fully displacedPauwels Classification 1935I - up to 30 degreesII - 30 - 50 degreesIII - greater than 50 degreesa line drawn thru the fracture on the AP x-ray in relation to a line from the horizontalBonus credit - look up Wards Triangle first described in 1838Support the show (https://www.patreon/TotalKneeTips)

I just wanted to share my thoughts and give you my two cents on where we may be in ten years. We still have 20% of patients that are dissatisfied after TKA. WHY?We get answers from industry - nav and robots?But, what is the question?Listen in to hear my thoughts on AR and AI and how a heads up display could help you decide how to best perform a TKA to get satisfaction rates up to 95% or higher.Support the show (https://www.patreon/TotalKneeTips)

"Modes of Failure" of Cemented Stem-type Femoral ComponentsGruen, McNeice and AmstutzCORR 1979Seven Gruen zones1 - proximal lateral 1/32 - central lateral 1/33 - distal lateral 1/34 - tip5 - distal medial 1/36 - central medial 1/37 - proximal medial 1/3Modes of FailureI. Pistoning     Ia. stem pistons in cement (punch-out crack)     Ib. cement pistons in bone (halo)II. Medial Midstem Pivot - medial migration of proximal stem, lateral migration of tipIII. Calcar Pivot - medial-lateral toggle of tip (windshield)IV. Cantilever Bending - loss of proximal support, tip is fixedSupport the show (https://www.patreon/TotalKneeTips)

Paprosky Classification of Femoral Bone LossType I - minimal metaphyseal bone lossType II - extensive metaphyseal bone loss, minimal diaphyseal bone lossType IIIA - extensive metaphyseal and diaphyseal bone loss with greater or equal to 4 cm intact diaphysis for "scratch fit"Type IIIB - extensive metaphyseal and diaphyseal bone loss with less than 4 cm of intact diaphysisType IV - extensive metaphyseal and diaphyseal bone loss with a non-supportive isthmusTreatmentsI - cylindrical fully porous coated stem (consider tapered proximal geometry or cemented stem)II - diaphyseal engaging stemIIIA - diaphyseal engaging stem (impaction grafting, modular stems)IIIB - tapered stem with splines for rotational stability (impaction grafting, modular stems, PFR)IV - PFR, impaction grafting with cemented stem, allograftsAribindi, Barba, Solomon, Arp, Paprosky. Bypass fixation. Orthop Clin North AM. 1998;29:319.Paprosky, Aribindi. Hip Replacement: treatment of femoral bone loss using distal bypass fixation. ICL 2000;49:119-130.Della Valle, Paprosky. The femur in revision total hip arthroplasty evaluation and classification. CORR 2004;420:55-62.Cross, Paprosky. Managing femoral bone loss in revision total hip replacement: fluted tapered modular stems. Bone Joint J. 2013;95 (11 supp A):95-97.Support the show (https://www.patreon/TotalKneeTips)

Kellgren, Lawrence. Radiological Assessment of Osteoarthritis. Ann Rheum Dis. 1957;16:494-502Grade 0 - No presence of OAGrade 1 - Doubtful narrowing, possible osteophytesGrade 2 - Possible narrowing, definite osteophytesGrade 3 - Definite narrowing, moderate osteophytes, some sclerosis and possible deformityGrade 4 - severe narrowing, large osteophytes, marked sclerosis, definite deformityX-rays finding of OAnarrowing of joint spaceosteophytessclerosis of subchondral bonepseudocystic changesaltered shapeInteresting short biography on Dr. Kellgren:https://academic.oup.com/rheumatology/article/42/5/708/1784848Support the show (https://www.patreon/TotalKneeTips)

The International Consensus Meeting on MSK Infection presented their new criteria in 2018Major Criteria1. Two positive periprosthetic cultures w/ phenotypically identical organisms2. A sinus tract communicating with the joint____________________Minor Criteria> or equal to 6 = infected4-5 = inconclusive< or equal to 3 = not infected___________________2 points for:Serum CRP 100 in acute or 10 in chronicorD-dimer 860 in chronic1 point for:ESR 30 in chronic3 points for:synovial WBC 10,000 in acute or 3,000 in chronicor leuk esterase ++ in acute and ++ in chronicorpositive alpha defensin2 points for:synovial PMN 90 in acute or 70 in chronic2 points for:single positive culture3  points for:positive histology3 points for:intraoperative purulenceICM Philly website: https://icmphilly.com/PJI Risk Calculator:  https://icmphilly.com/ortho-applications/prosthetic-joint-infection-pji-risk-calculator/Support the show (https://www.patreon/TotalKneeTips)

Total Hip Replacement in Congenital Dislocation and Dysplasia of the HipJohn Crowe, John Mani, Chitranjan RanawatJBJS 1979I - < 50% subluxationII - 50% - 75% subluxationIII - 75% - 100% subluxationIV - >100% subluxationSupport the show (https://www.patreon/TotalKneeTips)

Changes in Trabecular Pattern of the Upper End of the Femur as an Index of OsteoporosisManmohan Singh et alJBJS 1970Grade 6 - All normal trabeculae are visibleGrade 5 - accentuation of the principal compressive and principal tensile trabeculae          - Ward's triangle looks emptyGrade 4 - tensile trabeculae are reduced          - Ward's triangle opens up laterally          - border line between osteoporotic and normal boneGrade 3 - break in the continuity of the priciple tensile group          - definite osteoporosisGrade 2 - principal compressive trabeculae are the only prominent trabeculaeGrade 1 - all trabeculae are reducedThe Normal Trabecular Pattern1. Principal compressive group2. Secondary compressive group3. Greater trochanter group4. Principal tensile group5. Secondary tensile groupWards Triangle (first described 1838)An area in the neck between the principal compressive, secondary compressive and primary tensile groupSupport the show (https://www.patreon/TotalKneeTips)

Radiological Demarcation of Cemented Sockets in Total Hip ReplacementJesse DeLee and John CharnleyCORR 19763 Types/ZonesZone 1 - Superior lateralZone 2 - Central or MedialZone 3 - Inferior medialSupport the show (https://www.patreon/TotalKneeTips)

Hopefully your system does not go down but when it does here is your cheat sheet.1. ALWAYS DATE AND TIME2. SIGN and print your name and/or doctor number, pager number, etc3. Make sure the patients name and medical record number or DOB is on the pageA- AdmitD - DiagnosisC - Condition and Code StatusV - VitalsA - AllergiesA - ActivityN- NursingD - DietI - IVFM - MedicationsL - Labs and TestsS - Special - PT, OT, Case ManagementAnd DATE AND TIME ITCommon Meds after TKA - always check the medication, dose and frequency and the safety profile for the patient.Abx - Ancef 1 gm q8 (occ Vanco or other)VTE Prevention - Asa 81 mg BID (or 325mg or eliquis, xarelto, warfarin, enoxaparin, etc)Scheduled Pain Meds1. acetaminophen 1000 mg PO q82. celebrex 200 mg PO BID3. sometimes: gabapentin 100 mg PO q8Breakthru Pain Meds1. Tramadol 50 mg PO q6 prn mild pain (level 1-5)2. Oxycodone IR 5 mg PO q6 prn moderate pain (level 6-9)3. Oxycodone IR 10 mg PO q6 prn severe pain (level 10)4. sometimes: IV breakthru medicationsBowel - colace 100 mg PO BIDGI - pepcid 20 mg PO BIDPuritis - claritin 10 mg PO q day prn itchingNausea - zofran 4 mg IV q 6 prn nauseaHOME MEDS!if diabetic don't forget sliding scale insulinand DATE AND TIME the ordersSupport the show (https://www.patreon/TotalKneeTips)

Current Concepts ReviewImpingement with Total Hip ReplacementJBJB 2007Aamer Malik, MD, Aditya Maheshwari, MD, and Lawrence Dorr, MDFor hip stability:Evaluate the x-rays and templateBe wary of hypermobile patients and spine patientsKnow your implants (head options, neck options, etc)Check patients supine and again lateral (for posterior approach)Meticulous approachProper reaming and cup placement and remove osteophytesProper broaching and remove osteophytesCheck Ranawat sign1. 45 degrees for females2. 20 - 30 degrees for malesHow I test stability1. leg length2. capsular tension and palpate offset3. extension and rectus tension4. extension and external rotation5. position of sleep6. full flexion in neutral7. 90 degrees, slight adduction and internal rotation8. assess intraoperative x-raysThen make changes based on stability.Support the show (https://www.patreon/TotalKneeTips)

The Forty-five-Degree Posteroanterior Flexion Weight-Bearing Radiograph of the KneeThomas Rosenberg, Lonnie Paulos, Richard Parker, David Coward, Steven ScottJBJS 1988PA x-ray with the knee in 45 degrees of flexion and the patella touching the cassette. The beam is aimed at the inferior pole of the patella and aimed 10 degrees caudad,55 patients in 1981-1982 (age 19-70)Major narrowing in the medial compartmentAP xray - 25%Rosenberg - 85%Major narrowing in the lateral compartmentAP xray - 30%Rosenberg - 80%Additional advantage of identifying osteophytes in the notch, loose bodies, OCD and SONKSupport the show (https://www.patreon/TotalKneeTips)

Roentgenographic Analysis of Patellofemoral CongruenceAlan Merchant, Richard Mercer, Richard Jacobsen, Charles CoolJBJS 1974Merchant View - patient is supine on the x-ray table. The knees are flexed 45 degrees and the legs are strapped. The beam to femur angle is 30 degrees and the plate is positioned against the shins.Sulcus Angle of Brattstrom - angle formed by the highest points on the medial and lateral femoral condyles and the lowest point of the sulcusCongruence Angle - sulcus angle is bisected to establish the reference line. Another line is drawn from the apex of the sulcus to the lowest point on the patellar articular surface.Support the show (https://www.patreon/TotalKneeTips)

A Comparison of Four Models of Total Knee Replacement ProsthesesJohn Insall, Chitranjan Ranawat, Paolo Aglietti, John ShineJBJS 1976Support the show (https://www.patreon/TotalKneeTips)

The kinematics of the knee are so complex. You can not overlook the PFJ. We are taught early on about medializing the button and lateralize the femur and make sure your femoral rotation is correct. If not you are taught to do a lateral release.The balancing of the PFJ is so important. Overstuff it and you have pain and limited range of motion.  Too loose and you lose efficiency of the extensor mechanism.Here I will share some tips and my thoughts on what I look for when I do a TKA specifically focusing on the PFJ.Support the show (https://www.patreon/TotalKneeTips)

Its good to have an algorithm that works for you when describing an x-ray. Here I will go through my thought process to make sure that you cover everything and not miss things.Support the show (https://www.patreon/TotalKneeTips)

These two tips can be used when performing a hemiarthroplasty for a hip fracture. You may also consider it even if doing a THA for a fracture or a THA for arthritis in certain patients such as parkinson's disease.Check out my other episode on a more detailed explanation of how I do my posterior approach to the hip. - https://www.buzzsprout.com/725061/episodes/4250591Support the show (https://www.patreon/TotalKneeTips)

I find this topic a more difficult topic to teach than knee balancing. Everything is important to get a stable hip. You need a good approach, pre-op planning, implant positioning and the restoration of length and offset. You need to be aware of balancing and how to address anatomic on anatomic impingement, implant on anatomic and implant on implant impingement.Impingement with total hip replacement by Malik JBJBm 2007 - https://pubmed.ncbi.nlm.nih.gov/17671025/Support the show (https://www.patreon/TotalKneeTips)

References:Ng et al. Preoperative Risk Stratification and Risk Reduction for Total Joint Reconstruction. AAOS 2013Aram et al. Estimating an Individual's Probability of Revision Surgery After Knee Replacement. Am J of Epid 2018Gronbeck et at. Risk stratification in primary total joint arthroplasty. Arthroplasty Today 2019Florschutz et al. Estimating patient specific mortality after joint replacement. Osteoarthritis and Cartilage 2019Ziebma-Davis et al. Outpatient Joint Arthroplasty. J Arthoplasty 2019National Joint Registry online Risk Assessment tool. jointcalc.shef.ac.ukSupport the show (https://www.patreon/TotalKneeTips)

I first met Dr. Colwell when I came west to interview for a fellowship at Scripps Clinic. I had the pleasure to sit down and ask him some questions about orthopedics and his career. We talked for an hour and a half and I could have spent all day listening to his stories. We didn't have time to get to every question that I had for him so I hope we can sit down again soon for a second Dr. Colwell interview.Support the show (https://www.patreon/TotalKneeTips)

Know if it is fixed or correctableAssess the amount of osteophytesRelease MCL around to semimembranousAssess PCL if using CRConsider downsizing tibial and removing additional medial boneFurther Reading:Master Techniques Knee Arthroplasty - Lotke and LonnerChapter 7 by Scuderi and InsallAdvanced Reconstruction of the Knee AAOSChapter 27 - Varus Knee - Windsor and ChoiJAAOS Article Dr. Mihalko -  http://upload.orthobullets.com/journalclub/free_pdf/19948701_19948701.pdfSupport the show (https://www.patreon/TotalKneeTips)

I had the chance to sit down for the second time with Dr. Colwell. In this episode we cover teaching fellows, running two rooms, bilateral total joints and more.If you haven't listen to the first episode you can listen here:https://podcasts.apple.com/us/podcast/interview-with-dr-colwell/id1507691532?i=1000536512016Support the show (https://www.patreon/TotalKneeTips)

I discussed varus knees previously, here is my two cents on what I look for and how I approach the valgus deformity when performing a TKAKrackowI - min valgusII - deformity > 10 degree, medial soft tissue stretchingIII - severe, incompetent medial soft tissues, have constrained/hinge avail Support the show (https://www.patreon/TotalKneeTips)

SSI is the number one reason for unplanned admission after TJA.Biofilm can form within minutes and be mature within 24 hours. Biofilm contains approximately 80% ECM and 20% bacteria.Check out this lecture by Next Science that was given at AAOS 2021https://www.youtube.com/watch?v=5WPZ02t8hEs&list=PL226EPMMG9vYS9F1oDCU9SvOOBIqjJXze&index=6And this two part series:https://www.youtube.com/watch?v=cG3iOT4vZlA&list=PL226EPMMG9vYWosH11BTZh1_2g02R-M92&index=7&t=31shttps://www.youtube.com/watch?v=ZDXZFbCEilw&list=PL226EPMMG9vYWosH11BTZh1_2g02R-M92&index=8 Support the show (https://www.patreon/TotalKneeTips)

Whether you are doing a hemi or total, cementing the femoral component takes some skill. Here I will share with you my tips on how to get a good cement mantle.A link to the episode on cement grading:https://www.buzzsprout.com/725061/episodes/7501843 Support the show (https://www.patreon/TotalKneeTips)

I still do this every Friday (sooner if it is a complicated revision)Check the patient, age, BMI, nasal swab, dvt proph. Check the x-rays and make sure the implants are ordered. Review the labs and any clearances that are needed.Double check everything necessary with the patient the day of surgery.Make sure the room is set up with everything you need prior to the patient coming into the room. Support the show (https://www.patreon/TotalKneeTips)

I am happy to share my new book THE KNEE BOOK - A GUIDE TO THE AGING KNEEIt was written for patients and it is written to patients in easy to understand language.The book is a perfect recommendation for patients with knee pain that have questions.I believe it is also a great resource for residents and young surgeons. In it I review the algorithm for treating patients with knee pain from the most conservative up to knee replacement.What I think is the best benefit for young surgeons is all of the analogies I use to explain things to my patients. You can pick these up by reading the book so that you can better explain things to your patients.It is also a great read for non-orthopedic doctors, PA's or NP's. Anyone that treats knee pain patients. It explains why we need weight bearing x-rays and not MRI's and more.You can download the ebook at Amazon here:https://www.amazon.com/Knee-Book-Guide-Aging-ebook/dp/B09NLL58LG/ref=tmm_kin_swatch_0?_encoding=UTF8&qid=1639946441&sr=8-2You can get the paperback here:https://www.amazon.com/Knee-Book-Guide-Aging/dp/B09NKWMYFN/ref=tmm_pap_swatch_0?_encoding=UTF8&qid=1639946441&sr=8-2Available at Barnes and Noble as a Nook here:https://www.barnesandnoble.com/w/the-knee-book-a-guide-to-the-aging-knee-adam-rosen/1140795276?ean=2940161052846 Support the show (https://www.patreon/TotalKneeTips)

AR is something I am really excited about. Here is my two cents on the future of AR technology in total knees Support the show (https://www.patreon/TotalKneeTips)

I used nav in 2005 and was looking forward to robotics when they came on the scene. First it was Mako and now Rosa and Velys. Unfortunately, the powers that be have not allowed them in our system yet.I think it is important for residents and fellows to be trained with robots. It is a part of education today. Robotic training will help you land a job. Robotics may help you attract patients.Augmented reality may offer some of the same information because that technology is advancing quickly.But, you need to know how to do a manual total knee well. A robot may not be available. Software may be corrupt or fail. Garbage in, garbage out. If it doesn't look right or feel right do not just believe what you see on. a screen or a heads-up display. You need reps on manual total knees so you have a bailout if things don't work with the technology. Support the show (https://www.patreon/TotalKneeTips)

What you are looking for in a fellowship is a personal decision. I covered this topic before but we are in the middle of fellowship applications and most applicants have the same questions.Here I discuss volume, autonomy, approaches, implants, technology, clinic, revisions and finding a job. Support the show (https://www.patreon/TotalKneeTips)

LLD is a real issue. Here I will go over a number of things that can cause or lead to a LLD. I will share things I look for and how I talk to patients about LLD and what things you can do at the time of surgery to control for LLD. Support the show (https://www.patreon/TotalKneeTips)

Here is my take on the three new broach only collared hip stemsDepuy Actis130 degree neck shaft anglesizes 0-12high offset 6mm (sizes 0-3) and 8 mm (sizes 4-12)Zimmer Avenier135 neck shaft anglesizes 0-9high offset 6mmcollared and non-collared optionscoxa vara neck 126.5 degreesStryker Insignia130 degress neck shaft anglesizes 0-11high offset 5 mm Support the show (https://www.patreon/TotalKneeTips)

Here I share with some some tips and tricks on what I look for and what I do when caring for the 50 and older patient with knee pain that does not have severe arthritis and does have a meniscus tear.I also share some tips on what to do during boards collections to make sure you have copies of the intra-op photos and how I discuss the surgical findings with my patients in the office. Support the show (https://www.patreon/TotalKneeTips)

Do not take my word for it but do your research and verify everything. Here I'll review the four common cups many of us useZimmer G7 - ream under by 1 mm, 36 mm ID options at 50 with 10 degree and +5 lat offsetStryker Trident II Tritanium - ream line to line, 36 neutral option at 48 and 36 mm options with lip and offset at 52 mmDePuy Pinnacle - under by 1 mm, 2mm or line to line, 36 mm ID options at 52 mmSmith and Nephew - under by 1 mm or line to line, 36 mm ID option at 52 mmIf you are a 40 mm fan, you can get 40 mm with Zimmer at 54 mm, Stryker at 52 mm, Depuy and Smith and Nephew at 56 mm Support the show (https://www.patreon/TotalKneeTips)

Two studies have shown that essential amino acids (EAA) can help function, and suppress atrophy of the rectus after TKA.Dreyer et al. J Clinc Invest. 2013;123(11):4654-4666. Essential amino acid supplementation in patients following total knee arthroplasty. Ueyama et al. The Bone & Joint Journal Vol 102-B, No. 6, Supp A. Perioperative essential amino acid supplementation suppresses rectus femoris muscle atrophy and accelerates early functional recovery following total knee arthroplasty.The two brands I recommend to patients are Thorne ( https://amzn.to/3KPuC2i ) and Pure Encapsulations ( https://amzn.to/3ObJj1U ) Support the show (https://www.patreon/TotalKneeTips)

This is the 100th Episode of the Total Knee Tips & Pearls PodcastSome techy stuff on TKARecommended Distal Femoral Resections8mm - Stryker Triathlon9mm - DePuy Attune9.5mm - Smith & Nephew10mm - Zimmer Persona, DJO, MicroportAnterior Flange Angle to Prevent Notching3 degrees - S&N, Zimmer5 degrees - DJO, DePuy6 degrees - Microport7 degrees - StrykerRecommended Tibial Slope0 degrees - Stryker PS, Aesculap3 degrees - Stryker CR, Aesculap, Persona PS, Attune PS, Microport, S&N5 degrees - Attune CR7 degrees - Attune CR, Persona CR1 mm Poly OptionsStryker, Zimmer, Depuy, S&NMetal Sensitive OptionS&N OxiniumZimmer Ti-NidiumMicroport NitrXDJO ArmourCoatAesculap Advanced Surface TechnologyTJO AurumNarrow OptionsZimmer, DePuy, S&N, AesculapSmallest - Zimmer 1 Narrow (55.5 mm M/L, 48.1 mm AP)Biggest - Aesculap F8 (82 MM M/L, 80.5 mm AP)Lots of stuff! Check with your reps and always refer to the technique manual, this is just a brief review but does not take the place of training and education. Support the show

This is an important episode because we are all at risk. If you are in trouble or suffering ask for help, get help, seek help and ask for help again. If you see a colleague or friend who is having trouble ask how you can help and be sure to check in with them or seek help from your attending or other supervisors. Support the show

I am going to cover some of the things I consider when approaching Uni'sPlease take the time to leave a review and subscribe.Stay safe. Support the show