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A patient undergoes the procedure depicted in Figures A and B with standard components (non-gender specific). Which of the following outcomes most appropriately describes the difference in females compared to males for this procedure?
Greater implant survivorship
Decreased WOMAC scores
Increased rate of extensor mechanism rupture
Increased postoperative pain
Increased component osteoloysis
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Females undergoing total knee arthroplasty with standard (non-gender specific) components show improved implant survivorship compared to males.
MacDonald et al performed a Level 2 study of 3817 patients who underwent 5279 primary total knee replacements (3100 female, 2179 male) with a minimum of 2 years followup. They found that women demonstrated greater implant survivorship, greater improvement in WOMAC scores, equal improvements in SF-12 scores, and less improvement in only the Knee Society function and total scores.
Greene discusses the role of gender-specific implant designs that are currently marketed and their benefit to patients. The article concludes that the amount of attention that implant manufacturers have focused on female specific components(e.g. narrower M/L dimensions, decreased thickness of the anterior flange, and increased trochlear groove angle) is of interest, considering that there is no evidence suggesting that females have inferior outcomes with standard components.
MacDonald SJ, Charron KD, Bourne RB, Naudie DD, McCalden RW, Rorabeck CH
Clin. Orthop. Relat. Res.. 2008 Nov;466(11):2612-6. PMID: 18800216 (Link to Abstract)
J Arthroplasty. 2007 Oct;22(7 Suppl 3):27-31. PMID: 17919589 (Link to Abstract)
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A 55-year-old patient is scheduled for total knee arthroplasty. A radiograph is provided in Figure A. Each of the following are risk factors for heterotopic ossification EXCEPT?
Incorrect sizing of femoral and/or tibial components
History of trauma
Presence of preoperative osteophytes (hypertrophic arthrosis)
Heterotopic bone ossification (HO) following TKA has not been associated with valgus knee deformity. HO formation can be problematic both after a THA and TKA, but unlike the hip, it rarely becomes a clinical problem. The overall incidence of HO after TKA varies greatly among published studies, ranging from 15-50%. In the study by Dalury et al, they noted a 15% HO incidence. Among those with HO, 95% had osteoarthritis and 5% had a history of inflammatory arthritis. In their study, obese and male patients also had a higher incidence of developing post-operative HO. Toyoda et al in their study showed a significantly higher rate of HO in patients with osteoarthritis and pre-operative osteophyte formation (hypertrophic arthrosis). Overall, the signficant risk factors include hypertrophic arthrosis (often seen with trauma), male gender, and obesity.
Dalury DF, Jiranek WA
J Arthroplasty. 2004 Jun;19(4):447-52. PMID: 15188102 (Link to Abstract)
Toyoda T, Matsumoto H, Tsuji T, Kinouchi J, Fujikawa K.
J Arthroplasty. 2003 Sep;18(6):760-4. PMID: 14513450 (Link to Abstract)
Average 3.0 of 25 Ratings
A 65-year old healthy male has just undergone primary total knee arthroplasty. Which of the following is associated with use of a closed suction drain in this procedure?
Increased incidence of wound dehiscence
Increased incidence of transfusion
Decreased incidence of infection
Decreased incidence of hematoma formation requiring return to OR
Decreased pain scores on post-op days 1 and 2
The cited meta-analysis by Parker et al evaluated 18 studies with 3495 patients (3689 wounds) and demonstrated that closed suction drainage increases the transfusion requirements after elective hip and knee arthroplasty (relative risk, 1.43; 95% confidence interval, 1.19 to 1.72). They found no significant effect on wound hematoma, infection, or operations for wound complications.
Parker MJ, Roberts CP, Hay D
J Bone Joint Surg Am. 2004 Jun;86-A(6):1146-52. PMID: 15173286 (Link to Abstract)
Average 4.0 of 23 Ratings
A 62-year-old female underwent a primary total knee arthroplasty of the left knee 10 days ago. She presents to clinic with skin necrosis of the midline incision. There is no deep infection present upon aspiration of the knee joint. She undergoes superficial irrigation and debridement and is left with exposed patellar tendon as shown in Figure A. What is the most appropriate next step in management?
Split thickness skin grafting
Twice daily wet-to-dry dressing changes with Dakin's solution until healing by secondary intention
Latissimus dorsi free flap transfer
Vacuum-assisted closure device until healing by secondary intention
Medial gastrocnemius muscle flap transfer and skin grafting
Medial gastrocnemius muscle flap transfer and skin grafting is the most appropriate choice of the options listed (postoperative image shown in Illustration A).
Level 4 evidence by Ries describes 9 patients sustained skin necrosis after total knee arthroplasty. Seven of these cases were over the patella tendon or tibial tubercle, of whom 6 were treated with medial gastrocnemius flap coverage. Successful wound healing and salvage of the TKA was achieved in all cases. Ries concluded that necrosis of the proximal wound including the area over the patella can be treated by local wound care and skin grafting. However, skin necrosis over the tibial tubercle or patellar tendon requires muscle flap coverage to prevent extensor mechanism disruption and deep infection.
J Arthroplasty. 2002 Jun;17(4 Suppl 1):74-7. PMID: 12068411 (Link to Abstract)
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HPI - I had done a TKR yesterday and the patient was on an epidural infusion for pain management. 6 hrs post-op, when she was unattended she got up (patient claims to have heard a knock at her room door and wanted to open the door - patient had been drowsy due to the epidural which had a mixture of local anaesthetic and narcotic) from the bed and buckled down with the knee hyperflexed and was on the floor. She had wound dehiscence and I took her to theatre immediately following the fall.
Intra-operatively, I found full thickness dehiscence and MCL substance tear close to tibial insertion was noted. The medial parapatellar tissues were partly ripped and friable. I performed an MCL repair. Since we don't stock implants, there was no chance I could go for a revision to a constrained prosthesis. I was not prepared to wait for a day leaving the wound open and at risk of an infection. I've applied a knee brace.
What is your post-op rehab protocol in this situation?
HPI - A 67 year old patient presents complaining of a 1 year history of pain in his right knee. The pain is aggravated with walking and other activity. He notices an audible click and swelling around the right knee. The patient is 5 years status post a TKA in the same knee.
What is the most probable diagnosis?
HPI - 64 YRS 110 KG MALE PATIENT WAS OPERATED( TOTAL KNEE REPLACEMENT ) FOR RIGHT KNEE PAIN 3 MONTHS BACK. PATIENT DEVELOPED PAIN OVER THE MEDIAL SIDE OF THE KNEE AFTER 15 DAYS. PATIET IS ABLE TO WALK CLIMB STAIRS BUT COMPLAINING OF SEVERE PAIN WHILE GETTING OUT FROM CHAIR OR BED. HE HAD A HABBIT OF CROSSING LEGS WHILE SETTING. WHILE SLEEPING PT KEEPS HIS LIMB IN EXTERNAL ROTATION AND MID FLEXION ( POSITION OF EASE).
HOW TO TREAT THIS UNRESOLVED PAIN