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

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/

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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/4250591

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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.

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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.

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A Comparison of Four Models of Total Knee Replacement Prostheses

John Insall, Chitranjan Ranawat, Paolo Aglietti, John Shine

JBJS 1976

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Roentgenographic Analysis of Patellofemoral Congruence

Alan Merchant, Richard Mercer, Richard Jacobsen, Charles Cool

JBJS 1974

Merchant 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 sulcus

Congruence 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.

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The Forty-five-Degree Posteroanterior Flexion Weight-Bearing Radiograph of the Knee

Thomas Rosenberg, Lonnie Paulos, Richard Parker, David Coward, Steven Scott

JBJS 1988

PA 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 compartment
AP xray - 25%
Rosenberg - 85%
Major narrowing in the lateral compartment
AP xray - 30%
Rosenberg - 80%

Additional advantage of identifying osteophytes in the notch, loose bodies, OCD and SONK

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Current Concepts Review
Impingement with Total Hip Replacement
JBJB 2007
Aamer Malik, MD, Aditya Maheshwari, MD, and Lawrence Dorr, MD

For hip stability:
Evaluate the x-rays and template
Be wary of hypermobile patients and spine patients
Know your implants (head options, neck options, etc)
Check patients supine and again lateral (for posterior approach)
Meticulous approach
Proper reaming and cup placement and remove osteophytes
Proper broaching and remove osteophytes

Check Ranawat sign
1. 45 degrees for females
2. 20 - 30 degrees for males

How I test stability
1. leg length
2. capsular tension and palpate offset
3. extension and rectus tension
4. extension and external rotation
5. position of sleep
6. full flexion in neutral
7. 90 degrees, slight adduction and internal rotation
8. assess intraoperative x-rays
Then make changes based on stability.

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Hopefully your system does not go down but when it does here is your cheat sheet.

1. ALWAYS DATE AND TIME
2. SIGN and print your name and/or doctor number, pager number, etc
3. Make sure the patients name and medical record number or DOB is on the page

A- Admit
D - Diagnosis
C - Condition and Code Status
V - Vitals
A - Allergies
A - Activity
N- Nursing
D - Diet
I - IVF
M - Medications
L - Labs and Tests
S - Special - PT, OT, Case Management

And DATE AND TIME IT

Common 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 Meds
1. acetaminophen 1000 mg PO q8
2. celebrex 200 mg PO BID
3. sometimes: gabapentin 100 mg PO q8
Breakthru Pain Meds
1. 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 medications
Bowel - colace 100 mg PO BID
GI - pepcid 20 mg PO BID
Puritis - claritin 10 mg PO q day prn itching
Nausea - zofran 4 mg IV q 6 prn nausea
HOME MEDS!
if diabetic don't forget sliding scale insulin

and DATE AND TIME the orders

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Radiological Demarcation of Cemented Sockets in Total Hip Replacement
Jesse DeLee and John Charnley
CORR 1976

3 Types/Zones

Zone 1 - Superior lateral
Zone 2 - Central or Medial
Zone 3 - Inferior medial

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