A 38-year-old right hand dominant European man was referred for evaluation of left arm pain, numbness, tingling, and slight subjective weakness. Upon evaluation, he noted a five month history of pain extending from his shoulder down the lateral aspect of his left arm to the his thumb and index finger. He also complained of numbness and tingling in his left thumb and index finger. Upon questioning, he did note mild loss of fine motor function in both hands, but no balance, bowel, or bladder abnormalities. His past medical history was significant for congenital cardiac disease with a history of surgical transposition of the great vessels and current moderate cardiac myopathy.
He was found to have 5/5 strength with manual motor testing in all muscle groups except for his left bicep, which was graded 4/5. He was hyperreflexic in his bilateral brachioradialis and throughout his bilateral lower extremities. He had slight ataxia and positive Hoffman’s sign bilaterally. Sensation was slightly decreased in his left C6 dermatome.
Plain radiographs of the cervical spine showed straightening of cervical lordosis and moderate degenerative disc disease (DDD) from C5-C7 (Fig. 1).
MRI scan without contrast showed severe spinal stenosis, primarily from C5-7, with associated spinal cord compression and cord signal change. The posterior longitudinal ligament (PLL) appeared thickened from C5-C7. (Figs. 2a and 2b)
CT scan without contrast showed the aforementioned DDD as well as ossification of the PLL (OPLL) from C5-C7 with central bony stenosis (Figs. 3a and 3b).
Multilevel cervical spinal stenosis secondary to OPLL with myeloradiculopathy.
The numerous options were discussed with the patient including anterior cervical corpectomy with fusion, posterior cervical laminoplasty, and posterior cervical laminectomy with instrumented fusion. Given the patient’s loss of lordosis and multilevel stenosis with OPLL, a posterior laminectomy from C4-T1 with instrumented fusion from C4-T2 was chosen. It was felt that this option may help avoid the complications of dural tear and cerebrospinal fluid (CSF) leak associated with anterior decompression in patients with OPLL. Additionally, given his loss of lordosis, it was felt that a posterior instrumented fusion was required to prevent further progression of cervical kyphosis. The patient agreed with the procedure and informed consent was obtained. The patient was optimized medically for surgery.
The patient was positioned in the prone position using Mayfield head tongs. His head was elevated to decrease intraoperative bleeding. A posterior midline approach to the cervical spinal was performed. Lateral mass screws were placed bilaterally from C4-C6, and pedicle screws were placed bilaterally at T1 and T2. No screws were placed at C7 to facilitate placement of the rods.
We now proceeded with a posterior cervical laminectomy from C4-T1 with foraminotomies at bilaterally at C4-5 and C5-6 to address the radiculopathy. There was excellent decompression of the spinal canal with posterior migration of the thecal sac. Appropriately sized and shaped rods were placed and set caps were placed and tightened. Cross-links were placed for both stability and protection of the spinal cord from the posterior musculature. (Figs. 4a, 4b, 4c, 4d).
Local bone graft from the decompression was morcellized and combined with allograft demineralized bone putty. This was placed over the decorticated posterior elements following resection of the facet capsules and debridement of the facet joints.
For pain management, liposomal bupivacaine was used to provide long acting local anesthetic relief. A deep drain and vancomycin powder was placed. The incision was closed in multiple layers.
The patient was monitored on the telemetry unit due to his extensive cardiac history. He did well overall without cardiac complications and improvement of his preoperative symptoms. His post-operative pain was well controlled with the liposomal bupivacaine and IV and oral narcotics for 72 hours.
Intraprosthetic Dislocation of a Dual Mobility Bearing After Hip Dislocation
Alexander Sah, MD
This pleasant 79-year-old female had a series of problems after a metal-on-metal right hip replacement was done elsewhere in 2004. Due to elevated serum metal ion levels, the hip was revised in 2014 to a 28x48mm dual mobility bearing. Per the operative report, it was recognized by the recovery room X-ray that the incorrect head size was used, as the acetabular component inner diameter was actually 38mm. She was taken back to the operating room the same day for revision to the correct 28x38mm dual mobility system. Subsequently, hip instability ensued, and she had two hip dislocations after surgery. They were treated by closed reduction. She notes she was seen by her surgeon in early 2015, but no X-rays were taken. On a pain scale, the hip is rated a 5/10 and is intermittent. The pain is particularly bad when walking and going up stairs. She has been in physical therapy for 3 months without any improvement. She complains of stiffness, instability, limping, and pain. She notes grinding, catching, and instability of the right hip. She is referred for revision consultation.
The patient has a well-healed surgical incision. No masses palpated and no swelling was present. She has a noticeable Trendelenburg gait. Due to discomfort, she has limited hip range of motion. There is no detectable subluxation or crepitation with hip motion. X-rays reveal eccentric femoral head position within the acetabular component (Figure 1).
The acetabulum is in excessive abduction, and there is osteolysis adjacent to the acetabular component. Frog-lateral view shows eccentric femoral head position and lysis adjacent to the acetabular component (Figure 2). On closer inspection, there is a shadow lateral to the hip joint with defined margins, suspicious of the mobile polyethylene liner or a fractured fragment of it (Figure 3). Preoperative evaluation with ESR and CRP was negative for infection.
Upon exposure through the fascia, a small amount of clear fluid was encountered. The hip joint was mobilized to expose the posterior hip, and a foreign body was noted anterior to the femur. Exposure of the object revealed the mobile polyethylene bearing lodged between the anterior femur and the surrounding soft tissues (Figure 4).
With this intraprosthetic dislocation, there was disassociation of the femoral head from the mobile polyethylene liner. This complication is unique to dual mobility hip articulations. The mobile liner was becoming enclosed within the soft tissue, and a pocket formed. It migrated from the posterior aspect of the hip, around the side of the femur, to the front of the hip joint. It was removed and involved scar tissue. Tissue samples were sent for cell count and culture, which eventually returned negative for infection.
The posterior approach to the hip was performed, and the femoral head was visualized to be eccentric in the acetabular component and articulating superiorly. The femoral head was exposed and removed with protection of the neck taper. The acetabular component was then removed with an explant system and revised. The lytic areas were filled with bone graft prior to cup placement. A metal on polyethylene articulation was used (Figure 5).
The patient’s postoperative pain management included a multimodal approach that combined toradol, acetaminophen, and a periarticular injection of liposomal bupivacaine. The exparel medication was expanded to 100cc to have more volume to disperse throughout the tissues. The patient had an intolerance of narcotics, and was therefore relying on non-opioid pain management. She was able to ambulate comfortably the day of surgery and was discharged home safely the following morning.
The patient’s pain and stability were improved immediately after surgery. She had an uneventful postoperative course. Her limp improved with continued hip abductor strengthening. She had no episodes of instability. She subsequently required revision of the metal-on-metal hip on her opposite side, as her serum metal ion levels remained elevated prior to revision. She had pelvic lysis and metallosis and damage of her soft tissues at time of her left hip revision.
Failure of a metal-on-metal hip replacement: An unusual and severe case of corrosion
Alexander Sah, MD
The patient is a 79-year-old female with a 5 year history of R>L hip pain. She had anterior hip replacements done elsewhere about 10 years ago. Her gradual right hip pain has worsened over the past year. She now has sharp pain in the groin and at the side of the hip. She also has a worsening limp and depends on a cane for ambulation. She has tried injections, physical therapy, and requires norco for pain control. She has failed these nonoperative treatments, and is referred for revision consultation.
The patient has a well-healed surgical incision. She has a noticeable Trendelenburg gait. X-rays reveal a metal-on-metal hip replacement with satisfactory component alignment and fixation. Her right greater trochanter is essentially absent, from presumed osteolysis (Figure 1). Preoperative evaluation with ESR and CRP was negative for infection. Metal cobalt and chromium ion levels were significantly elevated. Of note, there is an insufficiency fracture of the greater trochanter seen on the opposite left side, also presumed to be due to corrosion and lysis.
AP pelvis shows lysis of nearly the entire right greater trochanter. A fracture of the left greater trochanter is also visualized.
Upon exposure through the fascia, a copious amount of thick discolored material was encountered (Figure 2). Material was sent for culture, which eventually returned negative for infection. Evaluation of the proximal lateral femur revealed severe osteolysis, with cortical defects laterally (Figure 3). The entire trochanter was essentially dissolved into the thick material previously removed.
Exposure of the hip was performed and the hip dislocated. There were three areas of potential metal corrosion or metal wear. First, the backside of the metal acetabular liner was at risk due to a prominent screw head. However, there were no signs of wear at the cup-liner interface. Second, there was also no appreciable damage or wear at the liner-head articulation. Instead, at time of femoral head removal, there was significant corrosion (Figure 4).
Severe corrosion discovered at the head-neck taper.
An extensive and thorough debridement was performed. The femoral stem was well fixed and retained. The taper was cleaned and a ceramic femoral head with a titanium sleeve placed. Due to the amount of abductor deficiency, and the absence of lateral proximal femur to act as host bone attachment for a potential allograft, a constrained liner was used (Figure 5).
With the extensive debridement and the amount of soft tissue damage from the corrosion process, pain management was dependent on liposomal bupivacaine injected throughout the surgical site. The exparel medication was expanded to 100cc to have more volume to disperse throughout the tissues. Revision arthroplasty procedures can benefit from having more volume of liposomal bupivacaine to optimize tissue infiltration and anesthetic overlap. A multimodal pain management protocol was also used, which allowed the patient to ambulate the day of surgery, and to be discharged home comfortably the following morning.
The patient’s pain improved almost immediately after surgery. She had an uneventful postoperative course. Her limp is mildly improved, but she understands that her abductor deficiency will persist because of the damage to her trochanter and abductors. She is relieved to have the source of her corrosion resolved, and to be able to now maximize her outcome with therapy. She is also scheduled for revision of her opposite left metal-on-metal hip replacement, which has a less severe case of corrosion.
A Case for Multi-modal Pain Management in the Elderly Patient
Michael P. Bolognesi, MD
An 89-year-old female presented with progressive pain, decreased function, and radiographic evidence of advanced degenerative joint disease affecting both of her knees. The patient failed to improve with conservative treatment options and elected to pursue total joint replacement. The conservative treatment options included assistive aid, NSAIDS, injections, and activity modification. The risks, benefits, and alternatives to surgery were clearly explained and she had a good understanding of the operation. One of the main concerns with a patient of this age is the ability to limit the amount of oral narcotics given the risk of numerous side effects including confusion, nausea, constipation, and altered appetite.
The patient was seen in the Pre Anesthesia Testing Clinic (PAT). A plan was formalized to use a regional technique with local blocks in conjunction with a multi-modal technique in regards to oral and IV adjunctive medications. In the pre-op holding area, spinal was placed at the L3-4 location with a single shot technique using a 22 G Quincke needle (100 mm length). The block drug was Isobaric bupivacaine at a concentration of 0.5%.
Posterior Capsular Block
The patient was placed in a supine position and the approach to this block was lateral. This was an ultrasound guided technique and is also referred to as a IPACK block. A 21 G Stimuplex needle was utilized and ropivicaine at the concentration of 0.25% with epinephrine 1:400K was the agent selected. The total volume injected under ultrasound visualization was 20mL.
Adductor Canal Block with Catheter
The patient remained in the supine position; an anterior approach and ultrasound guidance were used. The needle selected was an 18 G insulated, stimulating Tuohy needle 100m in length. The block drug was ropivicaine again at a concentration of 0.25% with epinephrine 1:400K. The total volume used was also 20mL. An indwelling catheter was placed. A sterile adhesive dressing was applied and positioned in such a way that it was covered by the tourniquet and out of the way of the sterile field.
The patient underwent an uncomplicated total knee arthroplasty. The operation itself was uneventful with 50 cc of blood loss. Intravenous TXA was used at a dose of 1 gram prior to incision and another dose at tourniquet release. The patient was able to ambulate 100 feet POD#0 on a walker.
The patient received IV dexamethasone (10 mg) pre-operatively as well as 24 hours later. Pre-emptive antiemetic treatment was initiated using a scopolamine patch pre-operatively. Oral and IV antiemetics were also ordered post-operatively on a PRN basis. The medication regimen we have in place on the floor is listed below.
Acetaminophen 650mg q6
Gabapentin 400-600mg q8 or Lyrica 100mg Q12 is an alternative
Celebrex 100-200 mg Q12
Oxycodone 5-15mg Q4h PRN
Dilaudid 0.5mg iv Q3h PRN for breakthrough severe pain.
This patient did not receive Oxycontin given her age and we used gabapentin as opposed to Lyrica due to concerns about insurance approval. We also did not use any Dilaudid IV for breakthrough. The patient received a total of four 5 mg oxycodone tablets during her 2 night stay in the hospital.
The patient went home on a similar regiment of medications. We made sure to continue the acetaminophen, anti-inflammatory medications, and gabapentin. This patient required very little oral narcotic at home (oxycodone 5 mg) and reported only using 5-6 tablets over the first few days at home.
Transition to Home Pump
This patient’s adductor canal catheter was connected to a continuous infusion pump running at 8 ml/hr in the hospital. Prior to discharge on POD #2, the Anesthesia Pain Service transitioned her to a home infusion pump that is portable in nature. This elastomeric pump automatically and continuously delivers a regulated flow of local anesthetic via the adductor canal catheter. The patient is able to remove the catheter at home after receiving simple instructions from the APS team. There is also a 24 hour call line for questions related to the pump and patients are advised about how to take oral pain medications prior to removal.
This patient had an excellent post-operative course and decided to have her other knee replaced approximately 4 months later. An identical technique was utilized and this time the patient was able to leave POD#1. There are numerous ways to perform multi-modal anesthesia and we certainly believe that this is not the only approach that should be used. Pericapsular injections as opposed to blocks may be able to deliver similar excellent results. We do feel strongly about using these techniques to avoid general anesthesia especially in this patient age group. We hope these techniques allow for better pain control, earlier ambulation, and a likely decreased length of stay without compromising patient outcomes and experience.
Minimally Invasive Solutions for Neck Related Arm Pain in an Athletic Physician
Dr. Nitin Bhatia
This is a very pleasant 44-year-old right hand dominant male physician whose problems started approximately one to two years ago. They began with acute onset of right shoulder pain, followed by increased pain in the right side of the neck radiating down the arm into his fingers. This arm pain was associated with paresthesias and fluctuating weakness. At that time, he received two-three months of physical therapy with traction, which helped improve arm strength. However, he had recurrent episodes and flare-ups of severe right-sided neck pain accompanied by debilitating symptoms of pain radiating to the upper neck, right scapula, shoulder blade, forearm, then to his hand where he had numbness, tingling sensation, and weakness in the biceps and hand grip. He gradually lost motor strength in the right arm, which affects his ability to perform long radiology procedures. After working for two hours, he feels that the right arm is fatigued and weaker. He denies any balance problems and does not have similar symptoms on the left side. He reports a constant coldness in the right hand and rates his pain as being 8 on a scale of 1 to 10. The pain is directly related to activities. He continues to do cervical traction at home as he has his own cervical traction device. He has tried cervical epidural steroid injections that provide temporary and limited relief.
Physical exam showed a positive Spurling sign to the right with decreased right biceps reflex and 4/5 strength in the right biceps. Otherwise, his exam was normal.
Imaging studies showed degenerative disc disease at C5-6 with loss of disc height [Figure 1], and right sided C5-6 foraminal stenosis [Figure 2].
The numerous options were discussed with this knowledgeable patient. He chose to undergo surgical intervention due to his increasing symptoms and failure to respond to non-surgical treatment. The different options included anterior cervical discectomy and fusion of C5-6 versus cervical total disc arthroplasty versus posterior right C5-6 foraminotomy. The patient chose to undergo a minimally invasive foraminotomy.
The patient was positioned in the prone position using Mayfield head tongs. His head was elevated to decrease intraoperative bleeding. A minimally invasive approach to the posterior cervical spine was performed using gradually larger tubular dilators. An appropriately sized working tube was placed and locked in position using a positioning arm attached to the OR table. The position of the tube was confirmed on multiple views of fluoroscopy [Figure 3A and 3B].
The operating microscope was used for the remainder of the case. A right sided laminoforaminotomy was performed. Excellent improvement of the foraminal stenosis was achieved.
For pain management, oral Celebrex was used preoperatively. Liposomal bupivacaine was used to provide long acting local anesthetic relief.
The patient reported immediate relief of his preoperative painful radiculopathy. He was discharged home within 24 hours of surgery. A cervical collar was provided for comfort, but the patient chose not to use it after 72 hours. For six weeks, pushing, pulling, and lifting were limited to 10 pounds. After the six week period, all restrictions were eliminated. Two weeks after surgery, the patient returned to work, including interventional radiology.
Tibial Component Loosening and Bone Loss in a Patient with Chronic Pain
Alexander Sah, MD
The patient is a 75-year-old female who underwent right total knee replacement in 1998 by her local surgeon. She did well until 4 years ago when she began to have knee pain. Radiographs indicated loosening of the tibial component (Fig 1). Evaluation at the time revealed that no infection was present. She was informed of the findings and component revision was recommended. Due to medical and social reasons, the patient chose not to have revision surgery. In particular, she had multiple lower spine surgeries and now requires chronic pain medications for her back pain. Radiographs show progression of loosening over time (Figs 2, 3). She now presents 4 years after her initial consultation.
At this stage, the patient has increased pain and leg deformity. Her leg alignment is in a greater degree of varus alignment. She realizes that her deformity is worsening as it affects her walking ability. She requires a walker to ambulate and can hardly perform her activities of daily living. On physical examination, her range of motion is from full extension to 120 degrees and she has expected instability to varus-valgus stress. Radiographs show significant leg deformity and tibial component loosening (Figs 4a, b, c).
At the time of her revision surgery, the tibial liner cannot be removed because the interface with the tibial component is sunken within the tibial cortex. The femoral component is removed with preservation of as much host bone as possible. When exposure of the proximal tibial is achieved, the tibial component and liner are able to be extracted as one piece because it is so loose. It is nearly completely subsided below the tibial cortical rim. The resulting tibial bone defect is significant (Fig 5). There is essentially only a shell of medial cortical bone remaining. The majority of the tibial metaphysis has eroded.
Intramedullary preparation of the tibia is performed to achieve press-fit of a tibial stem. It is also used to make a proximal tibial resection to maximize bone support of the tibial tray. Because of the size of the defect, a trabecular metal tibial augment is prepared for with reamers and trial broaches (Figs 6a, b). Improved bone support is achieved with the lower cone portion of the augment, to add to the cortical rim support. After trialing of the components, a constrained liner is used due to the laxity of the collateral ligaments.
Due to a history of spinal fusions, the patient underwent general anesthesia rather than an epidural/spinal. She has chronic pain due to her back surgeries and so she took norco and levorphanol prior to surgery. Multimodal pain management was even more important given her relative resistance to narcotics. Intravenous acetaminophen was used intraoperatively and long-lasting liposomal bupivacaine injections were performed at the conclusion of the surgical procedure. Intravenous ketoralac was also used post-operatively. The patient was able to walk a short distance the day of surgery and was safely discharged home two days after surgery (Figs 7a, b). In addition to her usual narcotic dosages, her pain was well controlled with the described medications. She had much less pain and improved ambulation nearly immediately after surgery.
Management of a Complex, Comminuted Humeral Head and Neck Fracture
Kevin D. Plancher, MD
A 55-year-old male athlete who enjoys skiing, swimming, running, and weight lifting presented to the clinic with constant left shoulder pain from the mid-arm into the biceps. The patient injured his shoulder 6 days prior in a skiing accident in Colorado. He consulted an orthopaedic surgeon in Colorado and indicated that he had dislocated his left shoulder and fractured his greater tuberosity and glenoid. He was provided with a sling without a pillow and was instructed to follow-up with his orthopaedic surgeon. The patient reported that he was unable to sleep through the night due to the severe pain he experienced with all shoulder and elbow movements, and complained of sharp twinges of pain that started in his shoulder and ran down his arm. He presented to the clinic wearing a sling without an abduction pillow.
Physical examination revealed global tenderness to palpation and ecchymosis along the anterior deltoid and biceps muscles. Due to pain, a thorough assessment of the patient's active and passive range of motion was not conducted. Forward flexion was limited to 10° with severe pain, adduction to 10°, and internal rotation at the side to neutral. X-rays demonstrated a comminuted greater tuberosity and humeral head fracture with evidence of step off and displacement of approximately 2cm.
CT scan revealed a comminuted proximal humerus fracture involving the surgical neck with multiple fracture fragments (Figure 1a-c). The greater and lesser tuberosities were separate fragments. The fracture had some mild varus impaction and intra-articular extension into the inferomedial humeral head.
Figures 1a-c: CT images demonstrating a comminuted, varus-impacted proximal humerus fracture involving the surgical neck and greater and lesser tuberosities with inferomedial intra-articular humeral head extension.
MRI revealed extensive post-traumatic changes in the soft tissue surrounding the comminuted proximal humerus fracture. The rotator cuff tendons remained largely attached to their normal insertions despite the multiple bony fragments. Underlying tendinosis and articular-sided tears of the distal infraspinatus tendon were also noted. Evaluation of the joint capsule and labrum were limited due to the extensive edema in the soft tissues surrounding the shoulder.
Based on the comminuted and complex nature of the fracture, open reduction internal fixation with a proximal humerus plate was performed nine days after initial presentation to the clinic.
The patient was brought to the operating room and placed in the beach chair position with the arm placed in 45 degrees abduction. The shoulder was meticulously prepped and draped, and a 10-12 cm incision was made using a standard deltopectoral approach. The cephalic vein was mobilized medially and its deltoid branches were cauterized using a Bipolar. Hemostasis was obtained with a Bovie. The coracobrachialis appeared hemorrhagic upon visualization.
A deltoid retractor was placed under the deltoid and a blunt 90 degree retractor was used to retract the coracobrachialis. Upon further inspection, the long head of the biceps tendon (LHBT) appeared to be entwined in the shaft through the fracture, so it was freed. We then released the superior aspect of the pectoralis major insertion to improve visualization.
The biceps tendon was then traced proximally and to the level of the coracoacromial (CA) ligament, which was preserved. A Hohmann retractor was then inserted over the CA ligament and a Hawkins retractor was used to retract the pectoralis major. No. 2 FiberWire suture was then passed through the supra/infraspinatus and subscapularis near their attachments onto the greater and lesser tuberosities, respectively, to assist with fracture reduction.
The fractures were then debrided of interposed callus. A bone hook was used to reduce the shaft to the proximal humerus and sutures were tensioned to reduce the tuberosities to the humerus. A three-hole proximal humerus locking plate was then positioned 10mm distal to the insertion of the supraspinatus on the greater tuberosity, with the anterior border of the plate immediately lateral to the bicipital groove and provisionally secured with 2mm Kirschner wires. Orthogonal fluoroscopic images were taken to confirm plate position and fracture reduction. The tuberosity sutures were then passed through the plate, and the plate was subsequently fixed to the shaft with bicortical fixation. X-Rays were repeated. The locking screws were inserted using a threaded drill guide, followed by the remaining two distal cortical screws. The humerus was guided through external and internal rotation to ensure that it moved as one unit and that the plate did not impinge. The shoulder was then taken through internal and external rotation under live fluoroscopy to ensure that none of the screws were penetrating the humeral head articular surface.
The No. 2 FiberWire used to secure the tuberosities was then tensioned and tied. The wound was copiously irrigated with Bacitracin and a second dose of antibiotics was administered. The wound was closed in a multi-layered fashion using Vicryl and Monocryl suture, then Steri-Strips and dry sterile dressing were applied.
The patient was placed in an arm sling with an abduction pillow for the first two weeks postoperatively. Pendulum and passive range of motion exercises were initiated at two weeks until four weeks post-op. At post-op week four, active assisted range of motion exercises as well as scapular retraction and depression exercises, were initiated avoiding cross body adduction. Strengthening of the rotator cuff was commenced eight weeks postoperatively. Full range of motion, particularly emphasizing forward elevation and external rotation, as well as posterior capsular and anterior chest wall stretching exercises were progressed over weeks eight through twelve.
The patient reported minimal pain and stiffness in the first weeks following surgery, which improved with time. Thirteen weeks following surgery, the patient reported no pain with movement and demonstrated 145° forward flexion, 150° abduction, 85° external rotation at 90° abduction, 65° external rotation at the side, and internal rotation to L5. There was no evidence of impingement on Neer or Hawkins maneuvers. He was negative for painful arc of abduction and painful cross body adduction with 5/5 strength in the deltoid, rhomboid, supraspinatus, subscapularis, infraspinatus, trapezius, and teres as well as 5/5 strength in abduction and external rotation against resistance. The patient returned to swimming and skiing at this time. X-rays taken six months after surgery showed good consolidation of the previous fracture site, good alignment of the plate and seven screws, and no signs of loosening (Figure 2a-f).
One year following surgery, the patient’s excellent outcome was maintained with range of motion further improved to 170° forward flexion, 150° abduction, 90° external rotation at 90°, 65° external rotation at the side, and internal rotation to L5.
Figure 2a-f:X-rays taken six months after surgery showing good consolidation of the previous fracture site, good alignment of the plate and seven screws, and no signs of loosening.
Management of Complex Osteochondral Defects: Osteochondral Allografts and Juvenile Particulated Cartilage
Kevin D. Plancher, MD
Allison M. Green, PhD
Stephanie C. Petterson, MPT, PhD
A 29-year-old female horseback rider and Pilates instructor with a history of three previous right knee surgeries presents to the clinic with right medial knee pain. The index procedure was a hamstring autograft anterior cruciate ligament (ACL) reconstruction by another orthopaedic surgeon in 2001. After falling from a horse in 2010, she subsequently underwent arthroscopic microfracture, removal of loose bodies, and partial, medial, and lateral meniscectomies at an outside institution, which did not resolve her right medial knee pain. She then underwent a revision arthroscopic microfracture procedure and medial meniscal repair in 2011. While the patient returned to horseback riding and Pilates, she reported her right knee never felt the same. She presented to our clinic in 2012, approximately 1 year after the revision microfracture surgery, with persistent right medial knee pain that worsens going up and down stairs, with prolonged standing and riding, and when she sits with her legs crossed.
Physical examination revealed no effusion or edema and tenderness over the medial joint line and posteromedial femoral condyle of the right knee, but not over the medial meniscus and there was no tenderness over the lateral joint line. Her right knee range of motion (ROM) was 0 to 135 degrees with pain on hyperflexion and hyperextension. Lachman, pivot shift, and anterior drawer tests were negative, but she exhibited a positive McMurray test. Varus and valgus stress testing revealed a 2 cm opening and she had a neutral limb alignment. She demonstrated 5 out of 5 symmetric quadriceps strength and denied any numbness or tingling. Physical examination of her left knee was insignificant.
MRI revealed loss of volume in the body and posterior horn of the medial meniscus, consistent with degeneration and a prior partial medial meniscectomy. There was a vertical signal in the posterior horn of the medial meniscus, possibly indicating a new, small vertical tear. There was grade IV chondral loss on the posterior weight bearing third of the lateral femoral condyle and on the anterior aspect of the medial femoral condyle (Figures 1a, 1b). Chondral delamination involving the medial facet of the patella with intact articular cartilage was also noted.
Based on her clinical exam and MRI results, a diagnosis of medial meniscus tear and osteochondritis dissecans was made. A non-operative course was initially attempted including a five week course of topical anti-inflammatory cream and Meloxicam, as well as a corticosteriod injection, which only provided temporary relief. The patient reported that the corticosteriod injection worked for 3 days before her pain returned, the anti-inflammatory cream provided relief for only about an hour, and Meloxicam only alleviated her pain for about 2 hours. The patient expressed interest in operative intervention and the use of osteochondral allografts to augment healing of her osteochondritis dissecans was discussed.
Prior to the procedure, the patient received general endotracheal anesthesia and intravenous antibiotics. Inferolateral, inferomedial, and accessory medial portals were placed, a synovectomy was completed from the medial to lateral side, and loose fragments were removed.
The ACL was probed and demonstrated a chronic, grade 1 tear of approximately 10% of the width of the ligament distally. Visible sutures from the hamstring graft were removed and the ligament was debrided. The PCL, MCL, and LCL were normal. The popliteus was synovitic and was debrided.
Next, attention was turned to the degenerative medial meniscus tear. Careful inspection revealed a complete, complex radial tear. All radial flaps and horizontal cleavage (white-red) that had reloosened since the previous repair were removed, as well as the multiple sutures from the previous repair. The tear was repaired by trephination. In the red-red posterior third, multiple sutures from the previous repair were again visualized, as well as flap tears resembling a bucket handle tear. The sutures, as well as the posterior horn of the meniscus, were removed to prevent any rubbing on the chondral surface. The lateral meniscus had an incomplete, degenerative, flap tear in the middle third of the meniscus (white-white) which was partially excised.
The chondral surfaces were then assessed. The medial femoral condyle demonstrated grade 4 osteochondral changes with a large 9x9cm defect. The medial tibial plateau, lateral femoral condyle, and lateral tibial plateau all displayed minimal grade 1 changes. The trochlear groove displayed grade 3 changes with a 1.9x2.1cm defect, and the patella demonstrated grade 2 osteochondral changes in the medial and lateral facets. The medial femoral condyle and trochlear groove also displayed evidence of previous microfracture. A chondroplasty was performed through the grade 2 changes on the patella and through the trochelar groove.
Next, the medial femoral condyle was more closely inspected, revealing soft, depressed, crab meat, fissuring, and fragmented chondral defects covering 85% of the condyle surface as well as the previously noted defect (Figures 2a-b). The defect was covered with a sizer to determine the best osteochondral allograft configuration to use. A size 9 graft was selected to be centered over the area of the defect. The exact length of the graft was measured to prevent any errors due to any slight variablilities, then the recepient site was prepared. The portal was opened with an 11 blade and spread with a Kelly, then the punch of the obturator was introduced. The obturator was moved from the punch to twist the operator 45 degrees counter-clockwise. Next, the mallet was introduced and used to advance the punch, which was positioned absolutely perpendicular to the articular cartilage of the medial femoral condyle in all directions. The depth was checked periodically around the entire circumference to measure perpendicularity and alignment. Bone was removed with the punch.
After the correct depth was achieved, the impaction cap was removed and the drill bit was connected and inserted to the 9mm end of the punch, which would function as the drill guide to maintain alignment (Figure 3). Following drilling, the hole was well-irrigated, and a 0.564 K-wire was used to drill a small hole in the center of the larger hole to allow blood flow to the back of the graft. The osteochondral allograft was then loaded into the delivery device, recessed approximately 1mm at the end. The delivery device was positioned over the recepient site to the exact same alignment then released into the hole (Figure 4). The overhanging 1mm was gently tapped in place until flushed with the cartilage (Figure 5). This exact procedure was repeated a second time using a 7mm osteochondral allograft plug. Following placement of the second osteochondral allograft plug, the articular surface was copiously irrigated. Next, the trochlear groove was visualized and the previously mentioned 1.9x2.1cm defect was covered with a particulated juvenile cartilage graft and fixed using fibrin glue.
Following placement of the osteochondral allograft plug and particulated juvenile cartilage, the parapatellar incision, subcutaneous tissue, and portals were closed with Vicryl or Monocryl, then Steri-Strips, dry sterile dressing, and Xeroform were applied.
Next, the right hip was meticulously prepped and draped for stem cell harvest through a small nick in the skin 5cm posterior to the anterior superior iliac spine was created. The inner and outer tables were identified. The fluted trocar provided with the bone marrow aspirate concentration (BMAC) system was placed in the midsection between the tables with a mallet. The trocar was turned about 15 degrees, and a syringe preloaded with anticoagulant was injected. Two 30mL syringes of bone marrow were aspirated with a 15 degree rotation of the handle of the Tuohy needle between aspirations. The wound was irrigated copiously and closed with Vicryl, 3-0 Vicryl subcutaneous, and subcuticular Monocryl before steri-strips and a dry sterile dressing were placed. The collected aspirate was concentrated according to manufacturer’s directions, and the resultant 10mL of stem cells were injected into the patient’s knee joint, visible through an 18-gauge spinal needle from a suprapatellar lateral approach.
The patient was then fitted for a brace of 30 to 75 degrees to allow for engagement of both the osteochondral allograft plug at 75 degrees and the particulated juvenile cartilage graft at 30 degrees. The patient was then returned to the recovery room in stable condition.
The day after surgery, the patient reported taking a 500mg Vicodin tablet in the morning and experienced a little pain following the surgery. She took anti-inflammatories for the first 2 weeks as needed. By 16 days after surgery, the patient reported icing as her only form of pain management and was pain-free at 6 weeks post-operatively.
Post-operative rehabilitation included progressive ROM using a CPM machine and weight bearing as tolerated for the first 6 weeks. Exercises during the first 6 weeks included biking with no resistance, straight leg raises, and open chain strengthening exercises. The patient progressed to full weight bearing, full ROM, and closed chain strengthening exercises from weeks 6-12 post-operatively. During weeks 12-26, the patient continued with progressive strengthening exercises and initiated a jogging program.
Post-operative MRIs revealed progressive osseous incorporation of the osteochondral allograft in the medial femoral condyle with reparative fibrocartilage overlying the graft at both 5 months (Figures 6a-b) and 12 months post-operatively (Figures 6c-d). One year after surgery, the patient reported that her knee was doing well. She was able to do the activities that she wanted to do including Pilates, barre classes, and horseback riding. She reported mild pain at the medial aspect of her knee only after very long walks and her barre classes. She was taking Motrin 400mg as needed for pain and was very happy with her knee progression. The patient is now 3 years status post-osteochondral allograft implantation with no pain and full return to all desired activities without any restrictions (Figures 7a, 7b).
An Unusual Failure of TKA: Surgical Considerations and Pain Management in the Revision Setting
Alexander Sah, MD
A pleasant 61-year-old female presents with a 2 year history of left knee pain. She had previously undergone uncomplicated left total knee replacement at an outside institution. She reports that she was doing well until she fell and broke her left hip in 2012, which was treated locally to her. She feels she has not walked well since that injury, and that her left knee symptoms worsened two years prior to presentation. She does not recall specific trauma. Her orthopaedic surgeon evaluated her, but no diagnosis was made. Overall, the pain has worsened in the past 3 months.
On a pain scale, the knee is rated an 8/10 and is constant. The pain is particularly bad with standing, walking, going up or down stairs, and twisting. The pain is located on the inside and front of the knee. The pain is described as sharp and she also complains of swelling, instability, and limping. She requires Tramadol for pain and other conservative treatment has included activity modification and knee bracing. She uses a walker for ambulation and is mostly housebound. She denies fevers, chills, or signs of infection.
Her past medical history is significant for depression, fibromyalgia, atrial fibrillation, kidney disease, and coronary artery disease. She takes eliquis for anticoagulation.
Patient is 5’3” and 235lbs, BMI of 41.6, in no acute distress. She is in a wheelchair and is unable to walk without a walker. She has a well-healed midline knee incision. The leg alignment is valgus, with moderate laxity to valgus/varus stress. There is a trace effusion with tenderness to palpation at the medial and lateral joint lines. Her passive knee range of motion is from 0-110 degrees, but there is a 15 degree active extension lag. Due to the size of the leg, it is difficult to assess anterior and posterior knee stability. Her motor, sensory, and vascular exams are intact distally.
Radiographs reveal an absence of space between the components on the AP view.
Her patella is tracking centrally.
A lateral knee X-ray shows a femoral component in an extended position with the anterior flange underneath the anterior femoral cortex.
There is more cement present adjacent to the femoral prosthesis than expected, suggesting a prior bone defect. The liner is seen disassociated from the tibial tray and dislocated anteriorly. The need for revision surgery was discussed with the patient. She understands that the dislocated liner requires revision. We discussed that while it is tempting to replace the liner only, there is a possibility that it may fail again if nothing else is revised. In addition, the malpositioned femoral component places her at risk for continued knee failure, or possible periprosthetic fracture. Furthermore, the suspected bone defects filled with prior cement may require additional stems or augments at time of revision. We also discussed the challenge of managing her postoperative pain given her history of fibromyalgia, pain medication use, and limitations due to existing kidney disease.
Preoperative workup was negative for infection by ESR and CRP, and intraoperative synovial fluid analysis, frozen section, and cultures were also negative. Upon exposure of the knee joint, the liner was protruding anteriorly. The liner was severely worn posteriorly. The suprapatellar pouch and medial and lateral gutters were re-established and debrided of inflamed synovium from poly debris. The femoral component was then exposed and its placement in extension was confirmed. The component was removed with care to preserve as much host bone as possible, but there was a large defect anteriorly from the notching of the index procedure and after removal of the prior cement. The tibia was then exposed and removed. There was significant lysis and loss of metaphyseal bone, which was more than expected based on the preop films. The cortex of the tibia was mostly intact and reasonably supportive.
The tibia was prepared for an intramedullary stem with hand reaming. A proximal tibial resection was then performed to establish proximal bone support. Because of the extent of metaphyseal bone loss, the tibia was prepared for a trabecular metal coupled tibial cone augment.
This provided improved proximal support of the component, maximizing contact to host bone. The femur was then prepared for a stemmed constrained component to bypass the anterior bone defect. Trial reductions were performed and there was appropriate knee motion and stability. A hybrid technique was used that cemented the components into place and a press-fit was used for the stems.
The tibial cone can be placed with or without cement, but was cemented in this case because of the quality of the host bone.
For pain management, intravenous Tylenol was used preoperatively. No NSAIDs were used because of her kidney and anticoagulation contraindications. A periarticular injection of Marcaine with epinephrine was performed for short-acting pain relief, and to possibly minimize bleeding. Liposomal bupivacaine was first injected throughout the posterior capsule, medial and lateral gutters, and periosteum. Because of the size of the patient and the revision exposure, 100ml of diluted injection was used; a large volume allows optimization to create as large of a field block as possible. A 22-guage needle was used to maximize infiltration so that the injection stays within the tissue. Finally, the remaining injection was used in the soft tissues and skin prior to closure.
The patient tolerated the surgery well. Her pain was well controlled and she was able to ambulate the day of surgery. She had an unremarkable hospital course. She was discharged home the second day after surgery. At her two week appointment her incision was healing well, her pain was much improved compared to the pain she felt pre-surgery, and she was ambulating with a cane. At her 6 week appointment she was taking no pain medications and was walking without an assist device.
Treatment of Severe Genu Valgus Deformity with Total Knee Arthroplasty and Peri-articular injection in a patient with previous history of narcotic induced delirium
Ryan M. Nunley, MD
A very pleasant 65-year-old female presents to clinic with longstanding bilateral knee pain. Her right knee pain is worse than the left and she notes that she has always had a “knock-knee” appearance to her legs since she was a child. She had a deep brain stimulator placed six months prior to presentation as part of her treatment for Parkinson’s disease. Since that time, she has developed progressive exacerbation of her right knee pain. She has been managed by her primary care physician with physical therapy, oral medications, and she did receive an intra-articular steroid injection that only provided 1 week of relief. She never had any surgeries on her knees. She does mention that she did receive narcotic pain medication following her deep brain stimulator placement and this led to severe narcotic induced delirium requiring a prolonged hospital stay with close observation. She had a 24-hour sitter in her room for 2-3 days before her mental status improved. She comes in seeking potential management with surgery to improve the pain and knee function as she has been told by her physical therapist that her knee dysfunction is limiting her recovery following her deep brain stimulator for her Parkinson’s disease.
Her pre-operative X-rays are shown below.
The patient is 5 foot 5 inches, 205 lbs. with a body mass index of 34. On physical examination, the patient is alert and oriented but does have some slowing of her cognitive function as well as involuntary movements consistent with Parkinson’s disease. She also has spasticity and increased muscle tone in her bilateral lower extremities. She has difficulty walking on examination today and requires the use of a wheelchair for long distances and a walker for short distances inside her house and at the grocery store. Her right knee has significant valgus alignment of 20-25 degrees and is only partially correctable. Her right knee range of motion is 10-90 degrees of flexion. Distally she does have sensation intact to light touch through the L2-S1 nerve distributions, 5/5 strength in the quadriceps, hamstrings, tibialis anterior, extensor hallucis longus, and gastrocs. She has palpable pulses in bilateral legs and good capillary refill.
We had a long conversation with the patient and her family about the goals of surgery, the complexity of her knee deformity, and the potential for peroneal nerve dysfunction post-operatively given her severe valgus deformity and knee flexion contracture. We also had a long conversation about the options for her type of anesthesia (general vs. spinal) and how to best treat her post-operative pain to reduce or avoid narcotic medications given her previous history of narcotic induced delirium.
On the day of surgery, our anesthesia team was able to successfully place a long acting spinal block and the patient received the routine pre-operative antibiotics. The patient was positioned supine on the operative table and the decision was made to perform her total knee arthroplasty procedure without the use of a tourniquet to attempt to reduce her post-operative thigh pain and need for narcotic pain medications.
During surgery we used minimal retraction on the soft tissue structures throughout the case to reduce surgical induced trauma and inflammation. We used a traditional anterior mid-line surgical incision with a medial peri-patellar arthrotomy to access the knee joint. After adequate exposure we made a distal femoral resection with 3 degrees of valgus and with 2 additional millimeters of bone resection (11 mm total) to ensure that we were contacting bone on the lateral femoral condyle with our distal femoral bone cut.
Given the patient’s relative hypoplasia of her lateral femoral condyle, we used Whiteside’s line and the transverse epicondylar axis to ensure proper rotation of the femoral sizing instrument prior to placing the 4-in-1 femoral cutting block and completing our bone preparation on the femoral side. We then turned our attention to the tibial side and used the standard extra-medullary guides to cut the tibia perpendicular to the mechanical axis. At this point we stopped to assess our flexion and extension gaps and, as expected, the lateral side was tight in both flexion and extension.
Next, we placed a lamina spreader between the femur and tibia and palpated the tight structures. We determined the Iliotibial band (IT Band) was tight so we performed a selective inside-out pie crusting release of the IT band and then reassessed our flexion-extension gaps. The lateral side was still too tight so we replaced the lamina spreader and palpated the tight arcuate fibers in the posterior-lateral corner of the knee. Using a bovie electrocautery device we carefully released these tight fibers, which helped improve the lateral side in extension. We were still too tight in flexion so we performed a selective lengthening of the popliteus which allowed the knee to be balanced. We then resurfaced the patella and then placed the trial implants to assess the range of motion, ligament stability, and patellar tracking. Once we were satisfied with the knee range of motion, soft tissue balance, and kinematics, we removed the trail implants.
Next, we carefully injected the peri-articular tissues with long-acting local anesthetic. The key areas to inject of the peri-articular tissues include the skin edges, quadriceps muscle fibers adjacent to the arthrotomy, periosteum of the distal femur medially and laterally, the residual meniscal beds, and the posterior capsule. Take special precautions when injecting the posterior capsule on the lateral side of the knee to avoid injecting into the neurovascular structures. Our preferred injection technique is to use a large volume (60-100 mL) of long acting anesthetic and to inject approximately 50-80 different locations with each site only receiving a small volume of injections (0.5-1.0 mL). This will help to ensure that a greater number of nerve fibers are covered with the injection. It’s highly recommended to avoid injecting a large amount of the local anesthetic into only a few areas as the local anesthetic does not have the ability to diffuse very far from the site of injection. The size of the injection needle is also quite crucial so to avoid having the injected fluid extravasate out of the tissues once the needle is removed. We recommend using a 22 gauge or smaller needle for the peri-articular injection.
Since this patient has a history of narcotic induced delirium in the past and we know that the knee is generally painful after knee replacement surgery, we hoped to reduce or eliminate the need for narcotics post-operative. To help increase our chances for minimizing post-operative pain and the need for narcotic breakthrough medications, we asked our anesthesia team to augment the patient’s spinal block and intra-operative peri-articular injection with a saphenous nerve block (also known as an adductor canal block). This block is administered in the recovery room prior to the patient being transferred to the inpatient floor.
Post-operatively this patient did very well and her pain was managed with oral Tylenol, intra-venous Toradol, and only 2 doses of Dilaudid for breakthrough pain during her physical therapy sessions. The patient was successfully discharged home on post-op day 3 with only Tylenol and Celebrex for pain. She returned to clinic at 4 weeks and was already doing remarkably well from her knee replacement and had not experienced any post-operative complications nor episodes of delirium. She was so excited about her new right knee that she was already inquiring when she could have her left knee replaced. Her four week post-operative radiographs are shown below.