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

Dr. Adam Rosen

Dr. Adam Rosen is an orthopedic surgeon who specializes in total joint replacement. He created this podcast which is aimed at interns, residents, fellows, and general orthopedists who are looking to dive into the details of total knee replacements. I do not claim that my way is the best way or the only way. My personal approach to my patients, total knee replacement surgery and the ever important post-operative recovery has been developed over the years. My protocols are ever changing based on scientific evidence and personal experience.I know many of you will want to jump right ahead to the operative step episodes - and that is okay. The first few episodes are not as exciting but they do contain important information in my opinion. If you jump ahead just be sure to come back and listen to the first few episodes.I will attempt to offer you my brain and the algorithm within it. Here I will share my thoughts and my approach to caring for total knee replacement patients. I hope that you learn something from this podcast. I hope that my thought process stimulates your thinking and approach. Most importantly I hope that I can offer one or more tips or pearls that may benefit your patients. If you like the information and have a friend or colleague that you think would benefit from the material please be sure to share this podcast with them. (Disclaimer: This is my opinion. Any information gathered is not medical education. Practitioners need to use their education and experience to determine how to treat their own patients.) read less

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Balancing Algorithm in TKA

Balancing Algorithm in TKA

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. & so much moreA bi-monthly podcast where we share the stories of our Caregivers, patients and...Listen on: Apple Podcasts SpotifySupport the show

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Balancing Algorithm in TKA

Balancing Algorithm in TKA

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. & so much moreA bi-monthly podcast where we share the stories of our Caregivers, patients and...Listen on: Apple Podcasts SpotifySupport the show

Using a Star System for Difficult Cases

Using a Star System for Difficult Cases

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. Support the show

The Outerbridge Classification

The Outerbridge Classification

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 1961The classification is as follows:1 - Softening and swelling2 - Fragmentation and fissuring less than 1/2 inch diameter3 - Fragmentation and fissuring greater than 1/2 inch diameter4 - exposed bone Support the show

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. Support the show

HO - Brooker Classification

HO - Brooker Classification

Brooker et al JBJS Vol 55-A 1973Class I - Islands of bone within the soft tissue around the hipClass II - Bone spurs from the pelvis or proximal femur , leaving at least 1 cm betweenClass III - Bone spurs from the pelvis or proximal femur, reducing the space between to less than 1 cmClass IV - bony ankylosis Support the show

Knee Joint Changes after Meniscectomy by T.J. Fairbankpublished JBJS - Br 1948The following radiological changes were seen after meniscectomy1. Ridge formation2. Narrowing of the joint space3. Flattening of the femoral condyle Support the show

Osteonecrosis Staging Systems

Osteonecrosis Staging Systems

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-Br0 - Preclinical and pre-radiographicI - Xray is normal but hip is symptomaticII - sclerosis and cysts on xrayIII - Crescent signIV - OA with a deformed headSteinberg, A quantitative system for staging avascular necrosis, JBJS-Br 19950 - Normal1 - Xray normal, BS +, MRI +2 - sclerosis and cysts on x-ray3 - crescent sign4 - flattening of the femoral head5 - joint space narrowed without acetabular involvement6 - advanced DJDfor stages 1 - 5 he further describes volume of involvementmild moderate 15% - 30%severe > 30% Support the show

Vancouver Classification

Vancouver Classification

Vancouver Classification by Duncan and Masri ICL 1995Treatment options added in CORR 2004Type AAL - lesser trochanter - non-op unless larger medial pieceAG - greater trochanter - non-op unless >2.5 cm displacementType BB1 - well fixed stem - ORIFB2 - loose stem, adequate bone stock - revision w/ ORIFB3 - loose stem poor bone stock - revision w/ allograft or PFRType CC - fracture below the tip of the stem - ORIF Support the show

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 radiolucencyC - radiolucencies 50% - 99%D - complete radiolucent line 100% and/or failure to cement the tip of the stem Support the show

Dorr Classification

Dorr Classification

Dorr Classification; Bone 1993"Structural and Cellular Assessment of Bone Quality of Proximal Femur"A - Thick cortex - champagne flute canalB - Thin cortex with residual funnel shapeC - Thin cortex - "stove pipe canal"Canal/Canal RatioA - B - 0.5 - 0.75C - >0.75 Support the show

AORI ClassificationType 1 - Minimal bone defect, intact metaphysis - Treat with cement or impaction graftingType 2A - Metaphyseal bone damage of 1 femoral condyle (F2A) or 1 half of the tibial plateau (T2A); posterior condyles are reduced - Treat with cement, augments, bone graft, cones/sleevesType 2B - Metaphyseal bone damage of bone femoral condyles (F2B) or both sides of the plateau (T2B) - Treat with cement, augments, bone graft, cones/sleevesType 3 - Massive bone loss of large portion of the condyles and/or plateaus; can involve the collaterals and/or patellar tendon - Treat with allograft, custom implants, sleeves/cones/augments, hinge, DFRA Classification of Bone Defects, In: Revision Knee Arthroplasty. 1997 p 63-120Engh and Ammeen1. Classification and Pre-operative Radiographic Evaluation. Ortho Clinics N. Amer 1998 Apr; 29(2) 205-17.2. Classification and Alternative for Reconstruction. ICL 1999, 48: 167-175. Support the show

Garden and Pauwels

Garden and Pauwels

Low-Angle Fixation in Fractures of the Femoral NeckGarden JBJS-B 1961Stage I - Incomplete and abducted or valgus impactedStage II - Complete and non-displacedStage III - Complete partially displacedStage IV - Complete fully displacedPauwels Classification 1935I - up to 30 degreesII - 30 - 50 degreesIII - greater than 50 degreesa line drawn thru the fracture on the AP x-ray in relation to a line from the horizontalBonus credit - look up Wards Triangle first described in 1838 Support the show

The Future of TKA's with AI

The Future of TKA's with AI

I just wanted to share my thoughts and give you my two cents on where we may be in ten years. We still have 20% of patients that are dissatisfied after TKA. WHY?We get answers from industry - nav and robots?But, what is the question?Listen in to hear my thoughts on AR and AI and how a heads up display could help you decide how to best perform a TKA to get satisfaction rates up to 95% or higher. Support the show

Gruen and Modes of Failure

Gruen and Modes of Failure

"Modes of Failure" of Cemented Stem-type Femoral ComponentsGruen, McNeice and AmstutzCORR 1979Seven Gruen zones1 - proximal lateral 1/32 - central lateral 1/33 - distal lateral 1/34 - tip5 - distal medial 1/36 - central medial 1/37 - proximal medial 1/3Modes of FailureI. Pistoning Ia. stem pistons in cement (punch-out crack) Ib. cement pistons in bone (halo)II. Medial Midstem Pivot - medial migration of proximal stem, lateral migration of tipIII. Calcar Pivot - medial-lateral toggle of tip (windshield)IV. Cantilever Bending - loss of proximal support, tip is fixed Support the show

Paprosky Classification of femoral bone loss

Paprosky Classification of femoral bone loss

Paprosky Classification of Femoral Bone LossType I - minimal metaphyseal bone lossType II - extensive metaphyseal bone loss, minimal diaphyseal bone lossType IIIA - extensive metaphyseal and diaphyseal bone loss with greater or equal to 4 cm intact diaphysis for "scratch fit"Type IIIB - extensive metaphyseal and diaphyseal bone loss with less than 4 cm of intact diaphysisType IV - extensive metaphyseal and diaphyseal bone loss with a non-supportive isthmusTreatmentsI - cylindrical fully porous coated stem (consider tapered proximal geometry or cemented stem)II - diaphyseal engaging stemIIIA - diaphyseal engaging stem (impaction grafting, modular stems)IIIB - tapered stem with splines for rotational stability (impaction grafting, modular stems, PFR)IV - PFR, impaction grafting with cemented stem, allograftsAribindi, Barba, Solomon, Arp, Paprosky. Bypass fixation. Orthop Clin North AM. 1998;29:319.Paprosky, Aribindi. Hip Replacement: treatment of femoral bone loss using distal bypass fixation. ICL 2000;49:119-130.Della Valle, Paprosky. The femur in revision total hip arthroplasty evaluation and classification. CORR 2004;420:55-62.Cross, Paprosky. Managing femoral bone loss in revision total hip replacement: fluted tapered modular stems. Bone Joint J. 2013;95 (11 supp A):95-97. Support the show

Kellgren-Lawrence Classification

Kellgren-Lawrence Classification

Kellgren, Lawrence. Radiological Assessment of Osteoarthritis. Ann Rheum Dis. 1957;16:494-502Grade 0 - No presence of OAGrade 1 - Doubtful narrowing, possible osteophytesGrade 2 - Possible narrowing, definite osteophytesGrade 3 - Definite narrowing, moderate osteophytes, some sclerosis and possible deformityGrade 4 - severe narrowing, large osteophytes, marked sclerosis, definite deformityX-rays finding of OAnarrowing of joint spaceosteophytessclerosis of subchondral bonepseudocystic changesaltered shapeInteresting short biography on Dr. Kellgren:https://academic.oup.com/rheumatology/article/42/5/708/1784848 Support the show

ICM 2018 Criteria for PJI

ICM 2018 Criteria for PJI

The International Consensus Meeting on MSK Infection presented their new criteria in 2018Major Criteria1. Two positive periprosthetic cultures w/ phenotypically identical organisms2. A sinus tract communicating with the joint____________________Minor Criteria> or equal to 6 = infected4-5 = inconclusive___________________2 points for:Serum CRP 100 in acute or 10 in chronicorD-dimer 860 in chronic1 point for:ESR 30 in chronic3 points for:synovial WBC 10,000 in acute or 3,000 in chronicor leuk esterase ++ in acute and ++ in chronicorpositive alpha defensin2 points for:synovial PMN 90 in acute or 70 in chronic2 points for:single positive culture3 points for:positive histology3 points for:intraoperative purulenceICM Philly website: https://icmphilly.com/PJI Risk Calculator: https://icmphilly.com/ortho-applications/prosthetic-joint-infection-pji-risk-calculator/ Support the show

Crowe Classification

Crowe Classification

Total Hip Replacement in Congenital Dislocation and Dysplasia of the HipJohn Crowe, John Mani, Chitranjan RanawatJBJS 1979I - II - 50% - 75% subluxationIII - 75% - 100% subluxationIV - >100% subluxation Support the show

Singh Index and Ward's Triangle

Singh Index and Ward's Triangle

Changes in Trabecular Pattern of the Upper End of the Femur as an Index of OsteoporosisManmohan Singh et alJBJS 1970Grade 6 - All normal trabeculae are visibleGrade 5 - accentuation of the principal compressive and principal tensile trabeculae - Ward's triangle looks emptyGrade 4 - tensile trabeculae are reduced - Ward's triangle opens up laterally - border line between osteoporotic and normal boneGrade 3 - break in the continuity of the priciple tensile group - definite osteoporosisGrade 2 - principal compressive trabeculae are the only prominent trabeculaeGrade 1 - all trabeculae are reducedThe Normal Trabecular Pattern1. Principal compressive group2. Secondary compressive group3. Greater trochanter group4. Principal tensile group5. Secondary tensile groupWards Triangle (first described 1838)An area in the neck between the principal compressive, secondary compressive and primary tensile group Support the show

DeLee and Charnley

DeLee and Charnley

Radiological Demarcation of Cemented Sockets in Total Hip ReplacementJesse DeLee and John CharnleyCORR 19763 Types/ZonesZone 1 - Superior lateralZone 2 - Central or MedialZone 3 - Inferior medial Support the show