Hip Complications Knee Complications

Transcription

1 Hip Complications Knee Complications Early Late Definition Less than 3 months

2 Stephen R Smith Orthopaedic Surgeon Northeast Nebraska Orthopaedics P C Norfolk Nebraska

3 Postoperative Course of the Total Joint Arthroplasty

4 Don t Fall!

5 Context present Column Category 1 Category 2 TKA Present 400,000 in Million THA Present 250,000 in ,000

6 Hip Complications Wound Infections Malposition Dislocations Heterotopic Bone Formation ALVAL

7 Knee Complications Wound Infections Quads Tear Stiffness Periprosthetic Fracture Loose Body Patella Tendon Tear Loosening Dislocations HBO

8 Hip Complications Knee Complications Wound Bruised and Cellulitis

9 Hip Complications Knee Complications Wound Bruised and Cellulitis

10 Hip Complications Knee Complications Wound Blisters

11 Hip Complications Knee Complications Wound Draining Clear Serosanguinous Bloody Pus

12 Hip Complications Knee Complications Wound Superficial wound Infections Knee 10.4% Hip 13.3%

13 Hip Complications Knee Complications Wound Draining Clear Serosanguinous Bloody Pus

14 Hip Complications Wound Open and Draining

15 Hip Complications Wound Infection Diagnosis Deep Superficial Suspect Suspect Suspect Redness Drainage Pain Temp. X Rays Not Helpful in Acute Infections Periosteal reactions not specific

16 Wound Infection Hip Complications X Rays Not Helpful in Acute Infections Periosteal reactions not specific

17 Hip Complications Wound Infection Incidence Nationally 1% FRHS 0.25% Risk Factors Include Previous Infection Immune Compromised RA,Lupus Malignancy Obesity

18 Hip Complications Knee Complications Prevention is the Best Cure Preoperative Antibiotics Laminar Flow Positive Pressure Time of surgery Open Wound

19 Hip Complications Knee Complications Risk Factors Immune Compromised HIV, Rheumatoid Chemotherapy/Suppressants Obesity Peripheral Vascular Disease

20 Risk Factors Diabetes???? Hip Complications Knee Complications Unitary Tract Infection Symptomatic Possible Asymptomatic????

21 Hip Complications Knee Complications Anticoagulants Previously used Low Molecular Weight Heparin Constantly Oozing Wounds Frequently Holding doses Now use Aspirin 325mg BID 6 weeks (AAOS Evidence Based)

22 Hip Complications Knee Complications 79 Yr Old Male on Xarelto Post Quads Repair

23 Hip Complications Knee Complications 79 Yr Old Male on Xarelto Post Quads Repair

24 Hip Complications Knee Complications 79 Yr Old Male on Xarelto Post Quads Repair

25 Hip Complications Wound Infection Blood Test CRP/Sed Rate/WBC Limited Value all raised Postoperatively at least 2 weeks or longer A low CRP<13.4mg/l may be of value to Exclude infection 3 Phase Bone Scan of No Value

26 Wound Infection Hip Complications Antibiotics Superficial Yes Deep No

27 Wound Infection Aspiration Grow at Least 5 days Commonest Staph.Aureus Worse Gram Negative (Rare) Hip Complications

28 Hip Complications Wound Infection Treatment (Early) Debridement and Implant Retention Exchange Polyethylene poss. Head Send Explanted Implant for Bact. (Parvizi)

29 Hip Complications Wound Infection Antibiotic Impregnated Beads How Long?

30 Hip Complications Wound Infection Treatment (Early) Antibiotics (dependent on Sensitivity) IV For 6 weeks in some series Oral for 1 yr.

31 Hip Complications Wound Infection Results Debridement and Retention Implants Estes et al 80% Byren 89% Did drop over time to78% Soriano 76.9% FRHS Numbers to low

32 Knee Complications Wound Infection Results Debridement and Retention Implants Byren 82% Trease et al 86% Jamsen 77%-!00% FRHS Numbers too Low

33 Dislocations Hip Complications Incidence Dependent on Head Size Small 22/26/28mm 3-6% Large >36mm 1% Personal series 0.15%

34 Hip Complications Factors Approach Posterior>Anterior Positional Cup 45 degrees Abduction 30 degrees Anteversion Femur degrees Anteversion Combined Anteversion at Least 45 degrees

35 Hip Complications Factors Impingement Bony or Soft Tissue Pelvic Obliquity Particularly Women Muscle Dysfunction Particularly Abductors

36 Hip Complications Factors Pelvic Obliquity Particularly Women

37 Dislocations Treatment Closed Reduction Hip Complications Open Reduction? Revise or Constrained Liner

38 Dislocations Treatment Constrained Liner Have Locking Ring Hip Complications

39 Hip Complications Heterotopic Bone Formation Occurs Men>Women Occurs Anterior approach> Posterior Occur Heterotopic OA>Atrophic OA Occurs one Side very very likely to occur on the other side TREAT!

40 Hip Complications Heterotopic Bone Formation Grading System Brooker 1-4 Gr 1 a little bit Gr 4 a lot

41 Hip Complications Heterotopic Bone Formation Grading System Brooker 1-4 Gr 1 a little bit Gr 4 a lot Incidence Many studies 50% Gr 1/2 39% Gr 3/4 11% ROM and Pain Gr 1/2 minimal Gr 3/4 significant

42 Hip Complications Heterotopic Bone Formation Treatment Radiation One Dose 7-8 Gy Preoperative Or within 72hrs Indomethacin 75 mg Daily for 6 weeks Surgical Removal (wait to Mature) Fair to Poor Results High Recurrence Rate

43 Hip Complications Heterotopic Bone Formation Heterotopic OA

44 Hip Complications Leg Length Discrepancy Probably the most litigated complication How to Avoid Pre-Operative planning Peri-Operative planning Like every complication higher in Obesity

45 Hip Complications Leg Length Discrepancy Anterior Approach Easy to Compare or Radiologically

46 Hip Complications Leg Length Discrepancy Posterior Approach Some form of Measurement

47 Hip Complications Limp Damage to the Abductor Muscles > In Anterolateral Approach RX Physical Therapy Core and Hip

48 Hip Complications Periprosthetic Fractures Intra-Operative Post-Operative Types

49 Knee Complications Persistent Postoperative Knee Pain Gabapentin has been Shown in several Studies to decrease opiod consumption Also has effect on Neurogenic or Burning Pain? Preoperative Dose How Much and How Long

50 Knee Complications Persistent Postoperative Knee Pain Be Aware of Complex Regional Pain Syndrome Treatment Epidural Sympathetic Blocks

51 Quads Tendon Tear Knee Complications Suspected on 6 week X Ray patella subluxation

52 Quads Tendon Tear Knee Complications During Rehab Very Weak Quad and Lag or Visible Patella Subluxation

53 Knee Complications Quads Tendon Tear Feel a Defect above Patella

54 Quads Tendon Tear Medial Para patella Repair can be Disrupted or Stretched No Tissue Attached to Superior Patella Knee Complications

55 Quads Tendon Tear Knee Complications Risk Factors Diabetes Obesity

56 Quads Tendon Tear RX My Technique Revise Patella to Suture Button provides Both a Polyethylene and Bone Anchor In the Patella Knee Complications

57 Quads Tendon Tear Suture Button Patella Knee Complications Predrilled Holes And Grooves For Sutures

58 Quads Tendon Tear Rehab Slow! Knee Complications Protect with T-Rom Brace No Flexion until wound healing The flexion Lock Brace at Flexion Range Obtained DC Brace only when Quads Control And Flexion>100 degrees

59 Knee Complications Patella Most Complications are Late and due to Falls!! Patella Loosening Remove or Replace

60 Knee Complications Patella Complications Resurfacing Patella 7% Complications Not Resurfacing Patella 7%

61 Knee Complications Patella Fracture Quads Intact No Pain? Pain Remove or Replace Quads Torn Repair

62 Knee Complications Patella Fracture Results of ORIF Poor Remove Button and Patellectomy

63 Knee Complications Nonresurfaced Patella in Total Knee Arthroplasy S.R.Smith P.Stuart I.M.Pinder J of Arthroplasty S

64 Flexion Contracture Knee Complications Within 10 degrees

65 Knee Complications Lack of Flexion Range of Flexion Post-op correlates with Pre-operative flexion Walking on Level ground Need 70 degrees Upstairs 90 degrees Downstairs 100 degrees Getting up from Low Chair 105 degrees

66 Knee Complications Lack of Flexion Post-op ROM Range degrees Average 118 degrees degrees? Treat

67 Knee Complications Flexion Contracture Physical Therapy Dynamic Extension Splint

68 Lack of Flexion Knee Complications Manipulation Under Anesthesia (MUA) Do Not Force (Leg Bounce) Complication Fracture Higher in Women Due to Higher risk of Osteoporosis

69 Knee Complications Lack of Flexion 66yr Female 6weeks Post TKA only 90 degrees Flexion Tibial Tubercle Undisplaced Fracture

70 Dislocation Rare Posterior Cruciate Retaining due Poor Soft Tissue Balance And Dysfunctional Posterior Cruciate Ligament Knee Complications

71 Knee Complications Unicompartmental Due to Flexion Extension Gap Mismatch In FRHS Series 5 dislocations 2 factors 1.Trauma 2. Obesity

72 Knee Complications Posterior Substituting TKA {PS} Posts of Various Designs Post control Roll Back High Flexion can lead to Dislocation Jump Height

73 Knee Complications Posterior Substituting TKA {PS} Posts of Various Designs Post control Roll Back High Flexion can lead to Dislocation Jump Height

74 Knee Complications Periprosthetic Fractures Common Supracondylar Nail It

75 Knee Complications Periprosthetic Fractures Common Supracondylar Plate It

76 Knee Complications Periprosthetic Fractures Common Supracondylar Replace It Several studies have Shown Superior Outcomes In Elderly Osteoporotic Females

77 Knee Complications Patella Tendon Tear Severe Loss Extension Very High Patella On X Ray

78 Knee Complications Patella Tendon Tear Post Total Knee Very Difficult Problem Can be Due to Excessive Mobilisation [More common in Obese Patients]

79 Knee Complications Patella Tendon Tear Avulsion from Tubercle Poss. Primary Repair Results otherwise Poor Intrasubstance need Augmentation Autograft or Allograft Achilles Tendon

80 Knee Complications Patella Tendon Tear Jaureguito JW,Dubois CM,Smith SR et al. Medial gastronemius transposition Flap For disruption of the extensor mechanism after total knee arthroplasty J Bone Joint Surg Am 1997,79,866

81 Knee Complications Patella Tendon Tear Jaureguito JW,Dubois CM,Smith SR et al. Medial gastronemius transposition Flap For disruption of the extensor mechanism after total knee arthroplasty J Bone Joint Surg Am 1997,79,866 Results Still had Significant Extensor Lag

82 Knee Complications Patella Tendon Tear 72yr Female Not Walked 15yrs Fall Supracondylar Fracture

83 Knee Complications Patella Tendon Tear Fall!!!!!

84 Knee Complications Patella Tendon Tear Tibia Patella Tendon Patella Distal Quadriceps Allograft

85 Knee Complications Patella Tendon Tear

86 Knee Complications Patella Tendon Tear

87 Surgery produces Walking Miracle

88 Hip Complications Knee Complications Hip Knee Society Las Vegas 2015 What Activities Can You Do After Hip or Knee Replacement Don t Fall!

89 Hip Complications Knee Complications Do Anything BUT Don t Fall!

90 Thankyou For Your Attention