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Knee Osteoarthritis in 76M with Comorbidities. Appropriate for ASC?
HPI
A 76-year-old male presents with severe left knee pain. Has had numerous cortisone injections over the past year, which failed to provide relief beyond 3 weeks. Tylenol and NSAID have also failed to provide relief. Pain wakes him up at night, and severely compromises his life. He is very active and wants to remain so.
PMH
CAD - 2006 - diagnoses - 1/2022 - CAD s/p stent - asymptomatic w/o nitro since Jan 2022 - able to climb a flight of stairs without any symptoms A-FIB - Symptoms consist of palpitations - Rate controlled with metoprolol - On Xarelto for DVT prophylaxis DM Type 2 - HgA1c 7.4 MODERATE AORTIC STENOSIS - diagnosed with TTE in January 2022 - LV Dysfunction w/ EF 45% PROSTATE CANCER - diagnosed on routine screening in 2014 - Treated with radiation in 2014 - On leuprolide for 3-4 years
PE
On physical exam, he has pain in medial and lateral joint lines with palpation. There is varus limb alignment, partially passively correctable with valgus stress. He has a 5-degree flexion contracture with flexion to 110 degrees with pain at extremes. There is crepitus with motion. He has no pain with hip ROM. Left lower extremity neurovascularly intact.
1.
In addition to plain film radiographs of the knee, would you obtain further imaging to guide management?
No - current radiographs are sufficient
49%
257/518
Yes - additional radiographic views (i.e full limb lengths, aXR)
34%
177/518
Yes - CT scan of the knee (CT)
5%
28/518
Yes - MRI of the knee (MRI)
4%
25/518
Yes - aXR + CT
1%
6/518
Yes - aXR + MRI
0%
4/518
Yes - CT + MRI
0%
5/518
Yes - aXR + CT + MRI
0%
3/518
Outside my area of expertise - best if I don't vote
2%
13/518
2.
How would you manage the patient at this time?
Nonoperative
6%
33/500
Operative
91%
458/500
Outside my area of expertise - best if I don't vote
1%
9/500
3.
During the Nonoperative management of this patient, what injections would you perform?
I would not perform any injections
28%
141/500
Steroid (S) only (includes long- and short-acting)
23%
117/500
Viscosupplementation (VS) only (e.g. Monovisc, Synvisc, etc.)
11%
59/500
Platelet rich plasma (PRP) only
2%
12/500
Stem cell (SC) only
0%
0/500
VS + S
20%
103/500
VS + PRP
5%
26/500
S + PRP
1%
8/500
VS + S + PRP
3%
15/500
VS + S + PRP + SC
1%
9/500
Outside my area of expertise - best if I don't vote
2%
10/500
4.
If you choose Arthroplasty, what procedure would you perform?
I would not choose Arthroplasty
0%
2/491
Total knee arthroplasty (TKA)
87%
432/491
Unicompartmental arthroplasty (UKA)
7%
35/491
Bicompartmental knee arthroplasty
1%
7/491
Will decide after visualizing compartment
1%
9/491
Outside my area of expertise - best if I don't vote
1%
6/491
5.
If you choose Total Knee Arthroplasty (TKA), what would you do with the PCL?
I would NOT choose TKA
1%
7/494
Sacrifice the PCL
46%
232/494
Retain the PCL
43%
213/494
Partial release of the PCL
5%
28/494
Outside my area of expertise - best if I don't vote
2%
14/494
6.
If you choose TKA AND Sacrificed the PCL, what type of bearing design would you use?
I would not choose TKA AND Sacrifice the PCL
10%
52/475
Fixed - standard bearing with POST
44%
211/475
Fixed - standard bearing without Post
12%
60/475
Fixed - Medial Stabilized bearing (medial pivot, medial congruence)
16%
80/475
Mobile - with POST
8%
39/475
Mobile - without POST
1%
9/475
Outside my area of expertise - best if I don't vote
5%
24/475
7.
If you choose TKA, what fixation strategy would you utilize?
I would not choose TKA
1%
8/477
Cement - all components
81%
390/477
Press-fit - all components
7%
37/477
Hybrid (cemented + press-fit)
7%
34/477
Outside my area of expertise - best if I don't vote
1%
8/477
8.
If you choose TKA, would you plan on using technology?
I would not choose TKA
1%
7/468
No
65%
305/468
Yes - Navigation
8%
38/468
Yes - Robotic assisted
13%
61/468
Yes - Patient Specific Instrumentation (PSI)
6%
32/468
Yes - Sensors
0%
3/468
Yes - Combination of above
1%
7/468
Outside my area of expertise - best if I don't vote
3%
15/468
9.
If you choose Total Knee Arthroplasty (TKA) with Navigation or Robotic Assisted, in what setting would you do it AND what would you post-op plan be?
I would not choose TKA with Navigation or Robotic Assisted
39%
174/445
Hospital - Admit patient at least overnight
44%
196/445
Hospital - Outpatient
6%
29/445
Outpatient Surgery Center - Send patient home
2%
12/445
Outpatient Surgery Center - Send patient to some monitored facility (SNF, apartment with nurse support)
3%
14/445
Outside my area of expertise - best if I don't vote
4%
20/445
10.
If you choose TKA, and were considering same-day outpatient surgery in this patient, who would evaluate and qualify the patient for same-day surgery?
I would not consider TKA same-day outpatient surgery in this patient
44%
196/444
Orthopaedic Surgeon (OS)
12%
56/444
Medical Doctor (Primary Care, Internist) (PC)
15%
67/444
Physician Assistant (APP)
2%
9/444
Medical Office Staff
0%
1/444
Physical Therapist (PT)
1%
6/444
Combination of OS + PC
20%
92/444
Outside of my area of expertise - best if I don't vote
2%
12/444
Other
1%
5/444
11.
If you choose same-day outpatient TKA at the ASC, what safety net would you implement in case the patient was not safe to go home?
I would not choose choose same-day outpatient TKA at the ASC
59%
247/412
None - No safety net needed for outpatient TKA
1%
7/412
Hospital Transfer Safety Net
23%
97/412
Skilled Nursing Facility / Rehab Facility
7%
30/412
Nurse Monitored Apartment
2%
12/412
Other
0%
4/412
Outside my area of expertise - best if I don't vote
3%
15/412
12.
If you performed an outpatient TKA at the ASC and sent the patient home, what would be your pain management strategy for the first 48 hours?
I would not perform outpatient TKA at the ASC
44%
176/395
Lower extremity block (e.g. adductor canal, IPACK) (Block) Alone
2%
10/395
Intra-operative peri-articular knee injection (Knee Injection) Alone
2%
10/395
Post-operative intra-articular pain pump (Pump) Alone
1%
6/395
Oral narcotics (Narcs) Alone
1%
7/395
Oral Narcotic Alternative (Gabapentin, NSAIDs, Acetaminophen) (Non-Narcs) Alone
2%
8/395
Narcs + Non-Narcs
3%
12/395
Block + Narcs
5%
20/395
Block + Narcs + Non-Narcs
18%
73/395
Pumb + Narcs + Non-Narcs
2%
9/395
Knee Injection + Narcs + Non-Narcs
10%
40/395
Other Combination of Above
3%
15/395
Outside my area of expertise - best if I don't vote
2%
9/395
13.
If you performed an outpatient TKA at the ASC and sent the patient home, would you give the patient your personal cell phone number?
I would not perform outpatient TKA at the ASC?
45%
176/385
No - I would not give my cell phone, just office on-call line
25%
100/385
No - I would not give my cell phone, but I would give my PAs (APPS) cell phone
6%
24/385
Yes - and tell them to call for "any concerns"
15%
60/385
Yes - but tell them to call "only for emergencies"
3%
14/385
Outside my area of expertise - best if I don't vote
2%
11/385
PROCEDURE #1
Total Knee Arthroplasty at ASC
OUTCOMES
Post-procedure P1