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Knee Osteoarthritis
Posted: Feb 23 2023 #(C102144)
A

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.

Poll
1 of 12
1. In addition to plain film radiographs of the knee, would you obtain further imaging to guide management?
No - current radiographs are sufficient
50%
264/528
Yes - additional Radiographic Views (aXR)
33%
178/528
Yes - CT scan of the knee (CT)
5%
29/528
Yes - MRI of the knee (MRI)
4%
25/528
Yes - aXR + CT
1%
6/528
Yes - aXR + MRI
0%
4/528
Yes - CT + MRI
1%
6/528
Yes - aXR + CT + MRI
0%
3/528
Outside my area of expertise - best if I don't vote
2%
13/528
2. How would you manage the patient at this time?
Nonoperative
6%
34/509
Operative
91%
466/509
Outside my area of expertise - best if I don't vote
1%
9/509
3. During the Nonoperative management of this patient, what injections would you perform?
I would not perform any injections
28%
144/509
Steroid (S) only (includes long- and short-acting)
24%
123/509
Viscosupplementation (VS) only (e.g. Monovisc, Synvisc, etc.)
11%
59/509
Platelet rich plasma (PRP) only
2%
12/509
Stem cell (SC) only
0%
0/509
VS + S
20%
103/509
VS + PRP
5%
26/509
S + PRP
1%
8/509
VS + S + PRP
2%
15/509
VS + S + PRP + SC
1%
9/509
Outside my area of expertise - best if I don't vote
1%
10/509
4. If you choose Arthroplasty, what procedure would you perform?
I would not choose Arthroplasty
0%
2/500
Total knee arthroplasty (TKA)
88%
440/500
Unicompartmental arthroplasty (UKA)
7%
35/500
Bicompartmental knee arthroplasty
1%
7/500
Will decide after visualizing compartments
2%
10/500
Outside my area of expertise - best if I don't vote
1%
6/500
5. If you choose Total Knee Arthroplasty (TKA), what would you do with the PCL?
I would NOT choose TKA
1%
7/503
Sacrifice the PCL
46%
236/503
Retain the PCL
43%
218/503
Partial release of the PCL
5%
28/503
Outside my area of expertise - best if I don't vote
2%
14/503
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
11%
54/484
Fixed - standard bearing with POST
44%
215/484
Fixed - standard bearing without Post
12%
61/484
Fixed - Medial Stabilized bearing (medial pivot, medial congruence)
16%
81/484
Mobile - with POST
8%
40/484
Mobile - without POST
1%
9/484
Outside my area of expertise - best if I don't vote
4%
24/484
7. If you choose Total Knee Arthroplasty (TKA), what technology would you use for implant positioning/balancing?
I would not choose TKA
1%
7/477
No Technology - Traditional Guides only
65%
312/477
Navigation (NAV) Alone
8%
39/477
Robotic assisted Navigation (ROBOT) Alone
12%
62/477
Patient Specific Instrumentation (PSI)
6%
32/477
Sensors (Sensor)
0%
3/477
Yes - Combination of above
1%
7/477
Outside my area of expertise - best if I don't vote
3%
15/477
8. 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%
179/454
Hospital - Admit patient at least overnight
43%
199/454
Hospital - Outpatient
6%
30/454
Outpatient Surgery Center - Send patient home
2%
12/454
Outpatient Surgery Center - Send patient to some monitored facility (SNF, apartment with nurse support)
3%
14/454
Outside my area of expertise - best if I don't vote
4%
20/454
9. 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%
201/453
Orthopaedic Surgeon (OS)
12%
58/453
Medical Doctor (Primary Care, Internist) (PC)
15%
68/453
Physician Assistant (APP)
1%
9/453
Medical Office Staff
0%
1/453
Physical Therapist (PT)
1%
6/453
Combination of OS + PC
20%
93/453
Outside of my area of expertise - best if I don't vote
2%
12/453
Other
1%
5/453
10. 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%
252/421
None - No safety net needed for outpatient TKA
1%
7/421
Hospital Transfer Safety Net
23%
99/421
Skilled Nursing Facility / Rehab Facility
7%
31/421
Nurse Monitored Apartment
2%
12/421
Other
0%
4/421
Outside my area of expertise - best if I don't vote
3%
16/421
11. 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%
180/404
Lower extremity block (e.g. adductor canal, IPACK) (Block) Alone
2%
10/404
Intra-operative peri-articular knee injection (Knee Injection) Alone
2%
11/404
Post-operative intra-articular pain pump (Pump) Alone
1%
6/404
Oral narcotics (Narcs) Alone
1%
7/404
Oral Narcotic Alternative (Gabapentin, NSAIDs, Acetaminophen) (Non-Narcs) Alone
1%
8/404
Narcs + Non-Narcs
2%
12/404
Block + Narcs
4%
20/404
Block + Narcs + Non-Narcs
18%
74/404
Pumb + Narcs + Non-Narcs
2%
9/404
Knee Injection + Narcs + Non-Narcs
10%
41/404
Other Combination of Above
3%
16/404
Outside my area of expertise - best if I don't vote
2%
10/404
12. 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?
46%
181/393
No - I would not give my cell phone, just office on-call line
25%
101/393
No - I would not give my cell phone, but I would give my PAs (APPS) cell phone
6%
25/393
Yes - and tell them to call for "any concerns"
15%
60/393
Yes - but tell them to call "only for emergencies"
3%
14/393
Outside my area of expertise - best if I don't vote
3%
12/393
PROCEDURE #1

Total Knee Arthroplasty at ASC

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OUTCOMES
Post-procedure P1
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