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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.

Poll
1 of 13
1. In addition to plain film radiographs of the knee, would you obtain further imaging to guide management?
No - current radiographs are sufficient
49%
261/524
Yes - additional radiographic views (i.e full limb lengths, aXR)
33%
177/524
Yes - CT scan of the knee (CT)
5%
29/524
Yes - MRI of the knee (MRI)
4%
25/524
Yes - aXR + CT
1%
6/524
Yes - aXR + MRI
0%
4/524
Yes - CT + MRI
1%
6/524
Yes - aXR + CT + MRI
0%
3/524
Outside my area of expertise - best if I don't vote
2%
13/524
2. How would you manage the patient at this time?
Nonoperative
6%
34/505
Operative
91%
462/505
Outside my area of expertise - best if I don't vote
1%
9/505
3. During the Nonoperative management of this patient, what injections would you perform?
I would not perform any injections
28%
142/505
Steroid (S) only (includes long- and short-acting)
23%
121/505
Viscosupplementation (VS) only (e.g. Monovisc, Synvisc, etc.)
11%
59/505
Platelet rich plasma (PRP) only
2%
12/505
Stem cell (SC) only
0%
0/505
VS + S
20%
103/505
VS + PRP
5%
26/505
S + PRP
1%
8/505
VS + S + PRP
2%
15/505
VS + S + PRP + SC
1%
9/505
Outside my area of expertise - best if I don't vote
1%
10/505
4. If you choose Arthroplasty, what procedure would you perform?
I would not choose Arthroplasty
0%
2/496
Total knee arthroplasty (TKA)
88%
437/496
Unicompartmental arthroplasty (UKA)
7%
35/496
Bicompartmental knee arthroplasty
1%
7/496
Will decide after visualizing compartment
1%
9/496
Outside my area of expertise - best if I don't vote
1%
6/496
5. If you choose Total Knee Arthroplasty (TKA), what would you do with the PCL?
I would NOT choose TKA
1%
7/499
Sacrifice the PCL
47%
235/499
Retain the PCL
43%
215/499
Partial release of the PCL
5%
28/499
Outside my area of expertise - best if I don't vote
2%
14/499
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%
53/480
Fixed - standard bearing with POST
44%
213/480
Fixed - standard bearing without Post
12%
60/480
Fixed - Medial Stabilized bearing (medial pivot, medial congruence)
16%
81/480
Mobile - with POST
8%
40/480
Mobile - without POST
1%
9/480
Outside my area of expertise - best if I don't vote
5%
24/480
7. If you choose TKA, what fixation strategy would you utilize?
I would not choose TKA
1%
8/482
Cement - all components
81%
394/482
Press-fit - all components
7%
38/482
Hybrid (cemented + press-fit)
7%
34/482
Outside my area of expertise - best if I don't vote
1%
8/482
8. If you choose TKA, would you plan on using technology?
I would not choose TKA
1%
7/473
No
65%
309/473
Yes - Navigation
8%
39/473
Yes - Robotic assisted
12%
61/473
Yes - Patient Specific Instrumentation (PSI)
6%
32/473
Yes - Sensors
0%
3/473
Yes - Combination of above
1%
7/473
Outside my area of expertise - best if I don't vote
3%
15/473
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%
177/450
Hospital - Admit patient at least overnight
44%
198/450
Hospital - Outpatient
6%
29/450
Outpatient Surgery Center - Send patient home
2%
12/450
Outpatient Surgery Center - Send patient to some monitored facility (SNF, apartment with nurse support)
3%
14/450
Outside my area of expertise - best if I don't vote
4%
20/450
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%
198/449
Orthopaedic Surgeon (OS)
12%
58/449
Medical Doctor (Primary Care, Internist) (PC)
14%
67/449
Physician Assistant (APP)
2%
9/449
Medical Office Staff
0%
1/449
Physical Therapist (PT)
1%
6/449
Combination of OS + PC
20%
93/449
Outside of my area of expertise - best if I don't vote
2%
12/449
Other
1%
5/449
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%
250/417
None - No safety net needed for outpatient TKA
1%
7/417
Hospital Transfer Safety Net
23%
97/417
Skilled Nursing Facility / Rehab Facility
7%
31/417
Nurse Monitored Apartment
2%
12/417
Other
0%
4/417
Outside my area of expertise - best if I don't vote
3%
16/417
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%
179/400
Lower extremity block (e.g. adductor canal, IPACK) (Block) Alone
2%
10/400
Intra-operative peri-articular knee injection (Knee Injection) Alone
2%
11/400
Post-operative intra-articular pain pump (Pump) Alone
1%
6/400
Oral narcotics (Narcs) Alone
1%
7/400
Oral Narcotic Alternative (Gabapentin, NSAIDs, Acetaminophen) (Non-Narcs) Alone
2%
8/400
Narcs + Non-Narcs
3%
12/400
Block + Narcs
5%
20/400
Block + Narcs + Non-Narcs
18%
73/400
Pumb + Narcs + Non-Narcs
2%
9/400
Knee Injection + Narcs + Non-Narcs
10%
40/400
Other Combination of Above
3%
15/400
Outside my area of expertise - best if I don't vote
2%
10/400
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%
178/389
No - I would not give my cell phone, just office on-call line
25%
100/389
No - I would not give my cell phone, but I would give my PAs (APPS) cell phone
6%
25/389
Yes - and tell them to call for "any concerns"
15%
60/389
Yes - but tell them to call "only for emergencies"
3%
14/389
Outside my area of expertise - best if I don't vote
3%
12/389
PROCEDURE #1

Total Knee Arthroplasty at ASC

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OUTCOMES
Post-procedure P1
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