Looks Good But 47 Year Old Professional Football Player IS Not - - PowerPoint PPT Presentation

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

Diagnostic Criteria

82 83 76 82 63 91 84 100 96 100 95 89 100 98 100 98 76 57 69 19 Combined 2,500 WBC and 60% PMN 60% PMN 80% PMN >2,500 WBC >50,000 WBC Negative Predictive Value Positive Predictive Value Specificity Sensitivity

Mason et al: J. Arthroplasty ‘03

The Value of WBC Counts Prior to Revision TKR

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
• Sense of instability

– Stairs – Standing from sitting

• Pain

– Pes Anserine

• Swelling
• Exam
• Effusion
• Posterior Sag at 90°
• 2+ or 3+ Draw

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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