Looks Good … But 47 Year Old Professional Football Player IS Not Happy Fred D. Cushner, M.D. Northwell Health Orthopedic Institute
Disclosures I have potential conflict with this presentation: • Smith and Nephew: Royalty & Consulting • CHE • Pacira • Acelity
Not To Be Confused With Looks Bad But Feels GOOD
Looks Good, Huh ?
Clinical Failure Prodromes of Failure • Symptoms – Pain 84% – Swelling 76% – Deformity 19% – Instability 17% – Stiffness 17% – Grinding 7% – Catching 4% Lonner et al: J.Arthroplasty 1999
Clinical Failure … In Many Cases it is not Patient Surgeon Prosthesis
Rule One Find a Junior Partner
Rule 2 Rule Out the Easy Sources of Pain
Hip DJD “Just Move It”
Spinal Stenosis
Don’t Forget the Merchant View
R/O Infection • History • CBC,ESR, CRP • Knee Aspiration – C and S – Cell Count
Aspiration Cell Counts • Acute • Chronic
Ghanem et al: JBJS 2008 • Cut-off Values – 1100 cells – > 64% Neutrophils • Over 98% accurate • Nearly 100% if CRO compared
Mayo Data • 1700 cells • > 65% neutrophils
The Value of WBC Counts Prior to Revision TKR Diagnostic Criteria >50,000 >2,500 80% 60% Combined WBC WBC PMN PMN 2,500 WBC and 60% PMN Sensitivity 19 69 57 76 98 Specificity 100 98 100 89 95 100 Positive 96 100 84 91 Predictive Value Negative 63 82 76 83 82 Predictive Value Mason et al: J. Arthroplasty ‘03
Further Radiographic Work-up as needed • CT • Bone Scan • Indium Scan • Sulfa Colloid Scan • MRI ( ?)
Other Risks • Ballet Dancer • Hyphen Last name • No Appendix, Uterus or Other Disposable Organs • Multiple Allergies • Workers Comp Case
Worker’s Compensation • Beware!! • Two studies
Worker’s Compensation • 42 patients vs. matched control • Mean age 48 years • 80 mo f/u • WC: 29% G/E 71% F/P 64 KSS • Control: 88% 12% 93 • No objective differences ROM or X-rays Mont et al: JBJS-A 1998
Worker’s Compensation • 23 TKA vs. matched control • Mean age 57 years • 56 mo f/u • Lower KSS in WC group • 5/21 patients returned to work Saleh et al: JOA 2004
Perhaps a bit late to be asking these questions
Pre-op X-ray How Bad was that DJD?
Fibromyalgia
Fibromyalgia and TKA • Trousdale et al – AAOS 2009 – 110 TKA with Fibromyalgia – 93% female – 50% continued pain • Post op – 17 % Pes Bursitis – 8% manipulation – 7% Revision
Pain History • Location • Degree • Activities
Possible Etiologies • Pes Bursitis • Pes Tendonitis • ITB Syndrome
Prosthesis Specific Pain
Arthroplasty
Fibrous Ingrowth Un-cemented Components • X-Rays – Sequential wt. bearing – Fluoroscopically positioned – Accurate to within 0.5mm Mintz et al: JBJS-A, 1989
Fibrous Ingrowth • X-Rays – Sequential wt. bearing – Fluoroscopically positioned
Patella Insufficiency Fracture • Seen at 1 year • X-rays may be normal • Re-vascularization event • Resolves with Time
Metal Allergy • Non Metal Options Available
Metal Sensitivity • History • Testing – Patch Test • Symptoms – 20 - 25% develop MS – Less than 1% with Symptoms
GRANCHI et al: Biomaterials 2008 • 4 x higher Failure in Metal Sensitive
Chronic Regional Pain Syndrome RSD For the Old Timers
Symptoms • Pain Out Of Proportion • Burning • Skin Sensitivity • Skin Temp Changes • Skin Color Changes – Purple/pale/red • Hair Growth
CRPS Symptoms • Harden et al: Pain 2003 • Predictors – Pre-op Pain – Pre-op Emotional Distess • CRPS TKS Patients – More Depressed 1 month – More Anxious 6 months
TKA and RSD/CRPS • Burns et al: J Orthop Surg, 2006 – 1280 pts – 8% CRPS – Improved with Treatment • Conclusion: Managed Early = Good Results
Neurologic Tourniquet Palsy • Combined motor/sensory • Isolated sensory • Sciatic or femoral distribution • Etiology – Cone vs. cylinder shape leg – Calibration Error!!! 2/8 had 40% error Rorabeck & Kennedy: AJSM 1980 Guanche: Arthroscopy 1995
Neurologic Tourniquet Palsy • Diagnosis – EMG & Nerve Conduction studies • Treatment – 4/5 resolved within 6 months • Avoidance – Max 350 to 400 mm for 90 to 120 minutes – Avoid re-inflation Rorabeck & Kennedy: AJSM 1980
Osteolysis
CT SCANS • Reish et al: J Knee Surgery 2006 – X-rays underestimate Osteolysis – CT vs X-ray – Only 17% CT lesions seen on X-ray
Osteolysis • Revision surgery must arrest the cause • Correct implant mal-alignment or instability • Eliminate implant design deficiencies
Patella Clunk
Patella Clunk
Clunk is Dead But What about Crepitus
Lonner et al: Am J Orthopedics 2007 • IB II vs NexGen • 150 each group • 4% vs 0%
Pagnano et al: AAOS 2009 • 599 PS TKA • 24% Crepitus • 68% - Non painful/audible – More Sx’s in LPS Group • Resolution – 23%
Dennis et al: Knee Society 2009 • 4000 TKA’s • 60 Developed crepitus requiring Surgery • More Common in – Shortened Patella Tendon Length – Smaller Patella Components
Instability • Effusion • Exam – Extension – Mid Range – Flexion
Flexion Instability PS knee • Dislocation – 0.2% Lombardi et al: J. Arthroplasty 1993
Flexion Instability CR knee • Flexion instability higher in CR knees Pagnano et al: CORR 1998 Waslewski et al: J. Arthroplasty 1998
Flexion Instability CR knee • Failure to balance intra-op • Late PCL rupture – 2% • Erratic kinematics Montgomery et al: Iowa Orthopaedic Journal v.13
Flexion Instability • Complaints • Exam • Sense of instability • Effusion • Posterior Sag at 90 ° – Stairs – Standing from sitting • 2+ or 3+ Draw • Pain – Pes Anserine • Swelling
One Last Rule Resist The Urge To REVISE Without a Cause!!!!
Revision TKR • Revision of TKR for unexplained pain – 27 Patients – 11 patients (41%) good/excellent results Mont MA et al: CORR 1996
You Can Not Cure Crazy !!
Thank You for Your Attention
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