hip and knee board review
TRANSCRIPT
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Hip and knee board review
Richard Crank DO, FAOA
Lakeland Regional Health
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No disclosures
Resources
Miller review
AAOS comprehensive review
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Femoral Acetabular Impingement
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Alpha angle
>42º=FAI
Center edge angle
<25º abnormal
Tonnis Angle
0-10º normal
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FAI
Cam
Incidence 50% in athletes
Pincer
OA occurs by contact of labrum and bone and leads to cartilage delamination
Evaluate FAI- order an xray
Look for coxa profunda-floor is medial to ilioischial line
Protrusio-head is medial to ilioischial line
Cross over sign=retroversion acetabulum
TX FAI:
<35, activity modification, NSAIDs, INJ
NEVER REMOVE the labrum: detach and fix
POOR outcome: older age female, low BMI, full thickness cartilage defect
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DDH
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DDH
Issue of undercoverage and labral pathology
Associated with early OA
NEVER REMOVE THE Labrum
TX:
<35, No OA, normal round head, restoration of acetabular coverage on maximum abduction xray, preservation of joint space
Bernese Periacetabular osteotomy-Ganz:
Bernese Periacetabular osteotomy-Ganz: improves acetabular coverage
Abducts acetabulum, medialization of hip center, retroversion of the socket, LEAVES INTACT posterior column
IT IS OK for vaginal child birth after
THA:
Prepare for anteverted femur, small acetabulum, acetabular bone defects (ant/sup and sup/lat), posterior trochanter, small femoral canal
PLACE socket in true acetabulum, not high
Correct femoral version
Femoral shortening osteotomy
Corrects version, corrects trochanter position, protects sciatic nerve from lengthening
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Ostenecrosis
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ON
Crescent sign=impending collapse
Look at the other hip
MRI most sensitive test
Tx depends on age, underlying diagnosis, extent of ON
IF combined alpha angle on coronal and sagittal xray >200 THEN POOR outcome if non-arthroplasty treatment
If collapse >2mm, poor outcome with non-arthroplasty
If acetabulum involved=DUE arthroplasty
PRECOLLAPSE Tx:
Core decompression with/without bone graft
Postcollapse: THA no matter what age
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TRANSIENT Osteoporosis of the
femur
DDX for ON
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Transient osteoporosis of the femur
Typical question: 37y/o female
with 3 month hx of severe hip pain
Workup:
Oder the MRI, it will differentiate
from ON
Most common
Women 3rd trimester
Males 5-6 decade
TX: NON SURGICAL
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OA
Arthroplasty: be conservative
Severe intractable pain for more
than 3 months
Wt loss, activity modification,
NSAIDs,
Steriod injection within 3-6 months
of surgery increases risk for
infection
FUSION of the hip
Incidence is most common for
exam answer
Most appropriate for septic hip
30º flexion, 0-5º ER, 0-10º ABD
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APPROACHES
DA: learning curve
Interval: Sartorius/TFL
Danger: LFCN, LF circumflex art
POST:
Interval: glut max/med, TFL
Danger: sciatic nerve
Higher dislocation
REDUCE by: POST CAPSULAR
REPAIR, larger head
Watson-Jones:
Interval: TFL/Glut med
Danger: femoral nerve, Sup glut
nerve, LF circumflex art
Direct lateral:
Interval: glut med/vast lateralis
Danger: sup glut nerve
PROLONGED LIMP
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Acetabular component
USE UNCEMENTED
Failure is due to poly wear and
osteolysis in CONVENTIONAL poly
POSITION:
40/20
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Safe zone for screws
POST/SUP and POST/INF
KNOW structures in zone of injury
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Femoral Component
Cemented have good outcome
and survivorship
Any pre-coated stem worse
survivorship with cement
Uncemented
Tapered or diaphyseal both good
Trunionosis: think about problem
with titanium stem and
cobalt/chrome head
Modular Neck:
Better control version, offset, length
Problems: fracture, fretting,
corrosion
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Polyethylene
Highly cross linked= decrease
wear and lysis
Vitamin E might decrease
osteolysis ?? Cost effective
POSITION OF COMPONENTS IS
IMPORTANT
Vertical is bad= higher wear
Re-melting: REMOVES free
radicals; REDUCES mechanical
properties
Annealing: LEAVES free radicals;
MAINTAINS mechanical properties
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Other bearings
Ceramic- decrease wear ?? Cost
MOM- higher failure than other bearing option
Larger head with MOM THA=higher failure
Higher revision in older patient
w/u painful MOM hip: NORMAL w/u first (infection, loosening)
Ions: They will give very high numbers in the question
Advanced imaging: U/S, MARS
Pseudotumor: LYMPHOCYTE, PLASMA CELL
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OTHER HOT HIP TOPICS Readmission 3.5-5.5% 30 day, 7% day
Risk factors fair game
Length of stay, SNF, gen anesthesia, blood transfusion
Intraoperative fracture: cable and stable; DO NOT change post op rehab protocol
LINER EXCHANGE only for well fixed, well positioned components with a GOOD tract record
Iliopsoas tendonitis:
Cause: large head, cup protrusion
Tx: conservative
Revise mal-positioned components
Tenotomy ONLY if good position components
HO:
NSAIDs are ONLY for prophylaxis
If treating HO: excision and single dose radiation
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Hip resurfacing
“Bone Conserving”
More acetabular bone loss, less
femoral bone loss
PROBLEMS:
MOM problems
Femoral neck fracture
High revision in women and
younger patients
INVERSE relationship between
head size and revision
Bigger heads better (NOT TRUE FOR
MOM THA)
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Revision hip
REVISE MALPOSITIONED
COMPONENTS ON TEST
Look at leg length, impingement,
offset
DUAL MOBILITY: it decreases
instability for those RESIVED for
instability
Problem: intra-prosthetic
dislocation
CONSTRAINED liner only if
DEFICIENT abductor AND well
positioned components
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Paprosky acetabular
I -hemispherical shell
IIa –
column intact: hemispherical shell
>50% uncovered augment to bring
cup down
IIb – sup lysis, up and out; sup/lat
Column intact: metal augment,
jumbo cup, high hip center
placement
IIc – medial defect; tear drop
gone, ischium intact
Hemispherical cup, RARE cage
IIIa – UP UP/ out; >3cm up, ischial
lysis
Augment, cup, cup/cage
IIIb – BAD; UP UP/in;
DISCONTINUTIY
Cage, triphlange, multiple
augments
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Paprosky
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Paprosky femoral
I – regular stem
II – metaphyseal loss
Fully porous coated or tapered Wagner
IIIa – metadiaphyseal loss
same stem
IIIb - <4cm scratch fit
Wagner, fully porous coated, PFR, Allograft composite
IV – massive loss
Impaction grafting, PFR, allograft
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Vancouver classification
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Vancouver classification
A- treat osteolysis
B1- well fixed stem, protection/ stabilize
B2,3 – revise
C - ORIF
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Knee OA
Wt loss, activity modification, inj
SCOPE is NOT answer for test
Osteotomy
<60, single compartment, good
motion, NO flexion contracture,
NO inflammatory
Closing: need fibular osteotomy,
LOSS post slope
Opening: higher nonunion rate,
slope maintained
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UKA
Lower long term survivorship in
most cases compared tka
Lower short term complications
compared to tka
Singe compartment disease only
never inflammatory
Failure: loosening, OA progression,
PF instability
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TKA
Cemented survivorship better than
uncemented
All other outcomes same, CR, PS,
patella resurface or not
There is a higher risk of revision with
patellar resurfacing
If you revise for pain to resurface
the patella ONLY 50% get better
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Gap balance
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Coronal balancing
Osteophytes
Varus deformity: Medial release
Deep MCL
Post medial corner with
semimembranosus
Pes
PCL
Valgus deformity: lateral release
Osteophytes
IT band if tight in extension
Popliteus if tight in flexion
LCL
RELEASE THE CONCAVE side
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tka
CAS increased outliers
Patient specific blocks decrease in
outliers
If cut MCL, INCREASE constraint
and repair
Patellar tracking: ER femur, ER
tibia, lateralize femoral
component, medialize patellar
component
Extensor mechanism disruption:
Acute: repair and augment with
hamstring autograft
Chronic: allograft/mesh THEY ALL
DO BAD, infection, lag
Arthrofibrosis: MUA < 12 weeks
Patellar clunk: occurs 45-30º flexion
ARTHROSCOPIC DEBRIDEMENT
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tka
Nerve injury most common with
valgus knee and flexion
contracture
Peroneal nerve
Tx: remove dressing and flex knee
Popliteal artery is posterolateral to
PCL
Dx EARLY
Dx late: poor outcome
Patella fracture
Conservative tx do best
UNLESS: implant loose or ext mech
disruption, must fix POOR outcome
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Knee revision
BMI >40:
decreased survivorship, increased
lucent lines, higher failure
Decreased functional scores but
have a higher delta
R/O hip cause for painful TKA
Causes: aseptic loosening,
instability, infection
POLY change is NEVER the answer
(unless says “what not to do”)
Stem fixation: hybrid stems must
engage diaphysis otherwise high
failure
Can retain patella if not oxidized,
well positioned, well fixed
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Knee revision
Periprosthetic fracture:
Know the bone quality
Frx displacement
Implant stable
Fix vs revise
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Infection
Major criteria
Sinus tract
2 positive cultures
Alpha defensin
High sensitivity/specificity
Adjunct only
UKA numbers
ESR 25
CRP 17
WBC 6500
PMN 72%
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infection
Risks: malnutrition, smoking,
uncontrolled DM, BMI > 40
MRSA screening decreases
incidence of infection
Antibiotics preop
Ancef or Clinda < 1 hour
Vanc - 2 hours before
ONLY FOR: MRSA carrier, region
with high MRSA, institutionalized,
health care workers
MOM must have manual cell
count because machine will count
particles
Wound drainage for 5-7 days:
Get labs
Aspirate
Washout deep space: open fascia
Due I&D early: < 3 weeks from
surgery or acute hematogenous
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infection
1 stage:
Must know organism
No soft tissue deficit; sinus tract
Not a poor host
Not for resistant organism
2 stage: gold standard
Infection
Early: staph
Late: staph epi, strep veridans, P.
Acne
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Other points
Tranexemic acid decreases blood
loss: all forms (oral, iv, topical)
VTE prophylaxis
Healthy: ASA
Everyone else with risk factors:
something stronger
SCD for everyone in perioperative
period
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GOOD LUCK