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

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.

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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/

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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.

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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.

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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.html

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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.

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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.

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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.

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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.

Listen on: Apple Podcasts   Spotify

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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.

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