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

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 radiolucency

C - radiolucencies 50% - 99%

D - complete radiolucent line 100% and/or failure to cement the tip of the stem

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Vancouver Classification by Duncan and Masri ICL 1995
Treatment options added in CORR 2004

Type A

AL - lesser trochanter - non-op unless larger medial piece
AG - greater trochanter - non-op unless >2.5 cm displacement

Type B

B1 - well fixed stem - ORIF
B2 - loose stem, adequate bone stock - revision w/ ORIF
B3 - loose stem poor bone stock - revision w/ allograft or PFR

Type C

C - fracture below the tip of the stem - ORIF

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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-Br

0 - Preclinical and pre-radiographic
I - Xray is normal but hip is symptomatic
II - sclerosis and cysts on xray
III - Crescent sign
IV - OA with a deformed head

Steinberg, A quantitative system for staging avascular necrosis, JBJS-Br 1995

0 - Normal
1 - Xray normal, BS +, MRI +
2 - sclerosis and cysts on x-ray
3 - crescent sign
4 - flattening of the femoral head
5 - joint space narrowed without acetabular involvement
6 - advanced DJD

for stages 1 - 5 he further describes volume of involvement
mild <15%
moderate 15% - 30%
severe > 30%

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Knee Joint Changes after Meniscectomy by T.J. Fairbank
published JBJS - Br 1948

The following radiological changes were seen after meniscectomy
1. Ridge formation
2. Narrowing of the joint space
3. Flattening of the femoral condyle

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Brooker et al JBJS Vol 55-A 1973

Class I - Islands of bone within the soft tissue around the hip
Class II - Bone spurs from the pelvis or proximal femur , leaving at least 1 cm between
Class III - Bone spurs from the pelvis or proximal femur, reducing the space between to less than 1 cm
Class IV - bony ankylosis

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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.

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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 1961

The classification is as follows:
1 - Softening and swelling
2 - Fragmentation and fissuring less than 1/2 inch diameter
3 - Fragmentation and fissuring greater than 1/2 inch diameter
4 - exposed bone

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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.

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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.

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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.

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