Total Knee Tips & Pearls From Dr. Adam Rosen (A Virtual Total Knee Fellowship Podcast)

I am going to cover some of the things I consider when approaching Uni's

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This is an important episode because we are all at risk. If you are in trouble or suffering ask for help, get help, seek help and ask for help again. If you see a colleague or friend who is having trouble ask how you can help and be sure to check in with them or seek help from your attending or other supervisors.

This is the 100th Episode of the Total Knee Tips & Pearls Podcast

Some techy stuff on TKA

Recommended Distal Femoral Resections
8mm - Stryker Triathlon
9mm - DePuy Attune
9.5mm - Smith & Nephew
10mm - Zimmer Persona, DJO, Microport

Anterior Flange Angle to Prevent Notching
3 degrees - S&N, Zimmer
5 degrees - DJO, DePuy
6 degrees - Microport
7 degrees - Stryker

Recommended Tibial Slope
0 degrees - Stryker PS, Aesculap
3 degrees - Stryker CR, Aesculap, Persona PS, Attune PS, Microport, S&N
5 degrees - Attune CR
7 degrees - Attune CR, Persona CR

1 mm Poly Options
Stryker, Zimmer, Depuy, S&N

Metal Sensitive Option
S&N Oxinium
Zimmer Ti-Nidium
Microport NitrX
DJO ArmourCoat
Aesculap Advanced Surface Technology
TJO Aurum

Narrow Options
Zimmer, DePuy, S&N, Aesculap

Smallest - Zimmer 1 Narrow (55.5 mm M/L, 48.1 mm AP)
Biggest - Aesculap F8 (82 MM M/L, 80.5 mm AP)

Lots of stuff! Check with your reps and always refer to the technique manual, this is just a brief review but does not take the place of training and education.

Two studies have shown that essential amino acids (EAA) can help function, and suppress atrophy of the rectus after TKA.

Dreyer et al. J Clinc Invest. 2013;123(11):4654-4666. Essential amino acid supplementation in patients following total knee arthroplasty. 

Ueyama et al. The Bone & Joint Journal Vol 102-B, No. 6, Supp A. Perioperative essential amino acid supplementation suppresses rectus femoris muscle atrophy and accelerates early functional recovery following total knee arthroplasty.

The two brands I recommend to patients are Thorne ( https://amzn.to/3KPuC2i ) and Pure Encapsulations ( https://amzn.to/3ObJj1U )

Do not take my word for it but do your research and verify everything. Here I'll review the four common cups many of us use

Zimmer G7 - ream under by 1 mm, 36 mm ID options at 50 with 10 degree and +5 lat offset

Stryker Trident II Tritanium - ream line to line, 36 neutral option at 48 and 36 mm options with lip and offset at 52 mm

DePuy Pinnacle - under by 1 mm, 2mm or line to line, 36 mm ID options at 52 mm

Smith and Nephew - under by 1 mm or line to line, 36 mm ID option at 52 mm

If you are a 40 mm fan, you can get 40 mm with Zimmer at 54 mm, Stryker at 52 mm, Depuy and Smith and Nephew at 56 mm

Here I share with some some tips and tricks on what I look for and what I do when caring for the 50 and older patient with knee pain that does not have severe arthritis and does have a meniscus tear.

I also share some tips on what to do during boards collections to make sure you have copies of the intra-op photos and how I discuss the surgical findings with my patients in the office.

Here is my take on the three new broach only collared hip stems

Depuy Actis
130 degree neck shaft angle
sizes 0-12
high offset 6mm (sizes 0-3) and 8 mm (sizes 4-12)

Zimmer Avenier
135 neck shaft angle
sizes 0-9
high offset 6mm
collared and non-collared options
coxa vara neck 126.5 degrees

Stryker Insignia
130 degress neck shaft angle
sizes 0-11
high offset 5 mm

LLD is a real issue. Here I will go over a number of things that can cause or lead to a LLD. I will share things I look for and how I talk to patients about LLD and what things you can do at the time of surgery to control for LLD.

What you are looking for in a fellowship is a personal decision. I covered this topic before but we are in the middle of fellowship applications and most applicants have the same questions.

Here I discuss volume, autonomy, approaches, implants, technology, clinic, revisions and finding a job.

I used nav in 2005 and was looking forward to robotics when they came on the scene. First it was Mako and now Rosa and Velys. Unfortunately, the powers that be have not allowed them in our system yet.

I think it is important for residents and fellows to be trained with robots. It is a part of education today. Robotic training will help you land a job. Robotics may help you attract patients.

Augmented reality may offer some of the same information because that technology is advancing quickly.

But, you need to know how to do a manual total knee well. A robot may not be available. Software may be corrupt or fail. Garbage in, garbage out. If it doesn't look right or feel right do not just believe what you see on. a screen or a heads-up display. You need reps on manual total knees so you have a bailout if things don't work with the technology.

AR is something I am really excited about. Here is my two cents on the future of AR technology in total knees

I am happy to share my new book THE KNEE BOOK - A GUIDE TO THE AGING KNEE

It was written for patients and it is written to patients in easy to understand language.

The book is a perfect recommendation for patients with knee pain that have questions.

I believe it is also a great resource for residents and young surgeons. In it I review the algorithm for treating patients with knee pain from the most conservative up to knee replacement.

What I think is the best benefit for young surgeons is all of the analogies I use to explain things to my patients. You can pick these up by reading the book so that you can better explain things to your patients.

It is also a great read for non-orthopedic doctors, PA's or NP's. Anyone that treats knee pain patients. It explains why we need weight bearing x-rays and not MRI's and more.

You can download the ebook at Amazon here:
https://www.amazon.com/Knee-Book-Guide-Aging-ebook/dp/B09NLL58LG/ref=tmm_kin_swatch_0?_encoding=UTF8&qid=1639946441&sr=8-2

You can get the paperback here:
https://www.amazon.com/Knee-Book-Guide-Aging/dp/B09NKWMYFN/ref=tmm_pap_swatch_0?_encoding=UTF8&qid=1639946441&sr=8-2

Available at Barnes and Noble as a Nook here:
https://www.barnesandnoble.com/w/the-knee-book-a-guide-to-the-aging-knee-adam-rosen/1140795276?ean=2940161052846

I still do this every Friday (sooner if it is a complicated revision)
Check the patient, age, BMI, nasal swab, dvt proph. Check the x-rays and make sure the implants are ordered. Review the labs and any clearances that are needed.

Double check everything necessary with the patient the day of surgery.

Make sure the room is set up with everything you need prior to the patient coming into the room.

Whether you are doing a hemi or total, cementing the femoral component takes some skill. Here I will share with you my tips on how to get a good cement mantle.

A link to the episode on cement grading:

https://www.buzzsprout.com/725061/episodes/7501843

SSI is the number one reason for unplanned admission after TJA.

Biofilm can form within minutes and be mature within 24 hours. Biofilm contains approximately 80% ECM and 20% bacteria.

Check out this lecture by Next Science that was given at AAOS 2021

https://www.youtube.com/watch?v=5WPZ02t8hEs&list=PL226EPMMG9vYS9F1oDCU9SvOOBIqjJXze&index=6

And this two part series:

https://www.youtube.com/watch?v=cG3iOT4vZlA&list=PL226EPMMG9vYWosH11BTZh1_2g02R-M92&index=7&t=31s

https://www.youtube.com/watch?v=ZDXZFbCEilw&list=PL226EPMMG9vYWosH11BTZh1_2g02R-M92&index=8

I discussed varus knees previously, here is my two cents on what I look for and how I approach the valgus deformity when performing a TKA

Krackow
I - min valgus
II - deformity > 10 degree, medial soft tissue stretching
III - severe, incompetent medial soft tissues, have constrained/hinge avail

I had the chance to sit down for the second time with Dr. Colwell. In this episode we cover teaching fellows, running two rooms, bilateral total joints and more.

If you haven't listen to the first episode you can listen here:

https://podcasts.apple.com/us/podcast/interview-with-dr-colwell/id1507691532?i=1000536512016

Know if it is fixed or correctable
Assess the amount of osteophytes
Release MCL around to semimembranous
Assess PCL if using CR
Consider downsizing tibial and removing additional medial bone

Further Reading:

Master Techniques Knee Arthroplasty - Lotke and Lonner
Chapter 7 by Scuderi and Insall

Advanced Reconstruction of the Knee AAOS
Chapter 27 - Varus Knee - Windsor and Choi

JAAOS Article Dr. Mihalko -  http://upload.orthobullets.com/journalclub/free_pdf/19948701_19948701.pdf

I first met Dr. Colwell when I came west to interview for a fellowship at Scripps Clinic. I had the pleasure to sit down and ask him some questions about orthopedics and his career. We talked for an hour and a half and I could have spent all day listening to his stories. We didn't have time to get to every question that I had for him so I hope we can sit down again soon for a second Dr. Colwell interview.

References:
Ng et al. Preoperative Risk Stratification and Risk Reduction for Total Joint Reconstruction. AAOS 2013
Aram et al. Estimating an Individual's Probability of Revision Surgery After Knee Replacement. Am J of Epid 2018
Gronbeck et at. Risk stratification in primary total joint arthroplasty. Arthroplasty Today 2019
Florschutz et al. Estimating patient specific mortality after joint replacement. Osteoarthritis and Cartilage 2019
Ziebma-Davis et al. Outpatient Joint Arthroplasty. J Arthoplasty 2019
National Joint Registry online Risk Assessment tool. jointcalc.shef.ac.uk