EditorJavad Parvizi MD FRCS

ProfessorDepartment of Orthopedic Surgery

Rothman InstituteThomas Jefferson University

Philadelphia, Pennsylvania, USA

Co-editorsWilliam J. Hozack MD

ProfessorDepartment of Orthopedic Surgery

Rothman Institute Thomas Jefferson University

Philadelphia, Pennsylvania, USA

Peter F. Sharkey MDProfessor

Department of OrthopedicsRiddle Memorial HospitalMedia, Pennsylvania, USA

Gregory K. Deirmengian MDAssociate Professor

Department of Orthopedic Surgery

Sydney Kimmel Medical CollegeThomas Jefferson University

Philadelphia, Pennsylvania, USA

New Delhi | London | Panama

The Health Sciences Publisher

Rothman Institute Manual of Total Joint

Arthroplasty Protocol-Based Care

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Rothman Institute Manual of Total Joint Arthroplasty: Protocol-Based CareFirst Edition: 2017ISBN: 978-93-86261-05-2Printed at:

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The views and opinions expressed in this book are solely those of the original contri butor(s)/author(s) and do not necessarily represent those of editor(s) of the book.All rights reserved. No part of this publication may be reproduced, stored or transmitted in any form or by any means, electronic, mechanical, photo copying, recording or otherwise, without the prior permission in writing of the publishers.All brand names and product names used in this book are trade names, service marks, trademarks or registered trademarks of their respective owners. The publisher is not associated with any product or vendor mentioned in this book.Medical knowledge and practice change constantly. This book is designed to provide accurate, authoritative information about the subject matter in question. However, readers are advised to check the most current information available on procedures included and check information from the manufacturer of each product to be administered, to verify the recommended dose, formula, method and duration of administration, adverse effects and contra indications. It is the responsibility of the practitioner to take all appropriate safety precautions. Neither the publisher nor the author(s)/editor(s) assume any liability for any injury and/or damage to persons or property arising from or related to use of material in this book.This book is sold on the understanding that the publisher is not engaged in providing professional medical services. If such advice or services are required, the services of a competent medical professional should be sought.Every effort has been made where necessary to contact holders of copyright to obtain permission to reproduce copyright material. If any have been inadvertently overlooked, the publisher will be pleased to make the necessary arrangements at the first opportunity.

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Jaypee Brothers Medical Publishers (P) Ltd

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Dedication Life brings us in contact with many. There are those

we will remember forever. I dedicate this to those who have made an indelible mark in my life.

Javad Parvizi

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Section Editors

Scot Brown MD

Fellow Rothman InstituteThomas Jefferson UniversityPhiladelphia, Pennsylvania, USA

Antonia F. Chen MD MBA

Assistant ProfessorRothman InstituteThomas Jefferson UniversityPhiladelphia, Pennsylvania, USA

Gregory K. Deirmengian MD

Associate ProfessorDepartment of Orthopedic SurgerySydney Kimmel Medical CollegeThomas Jefferson University Philadelphia, Pennsylvania, USA

William J. Hozack MD

ProfessorDepartment of Orthopedic SurgeryRothman Institute Thomas Jefferson UniversityPhiladelphia, Pennsylvania, USA

Paul B. McKenna MD

FellowRothman InstituteThomas Jefferson UniversityPhiladelphia, Pennsylvania, USA

Javad Parvizi MD FRCS

ProfessorDepartment of Orthopedic SurgeryRothman InstituteThomas Jefferson UniversityPhiladelphia, Pennsylvania, USA

Peter F. Sharkey MD

ProfessorDepartment of OrthopedicsRiddle Memorial HospitalMedia, Pennsylvania, USA

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Contributors

Pouya Alijanipour MD

Clinical Fellow of Spine and Pediatric Orthopedic SurgeryChildren’s Hospital of New OrleansLouisiana State UniversityNew Orleans, Louisiana, USA

Matthew S. Austin MD

Director of Joint Replacement ServicesDepartment of Orthopedic Surgery Rothman InstituteThomas Jefferson UniversityPhiladelphia, Pennsylvania, USA

Diana Bitar MD

Fellow, Department of Orthopedic Surgery Rothman InstituteThomas Jefferson UniversityPhiladelphia, Pennsylvania, USA

Scot Brown MD

Fellow, Rothman InstituteThomas Jefferson UniversityPhiladelphia, Pennsylvania, USA

Jenny Cai BS

Clinical Research CoordinatorDepartment of RadiologyUniversity of PennsylvaniaPhiladelphia, Pennsylvania, USA

David S. Casper MD

Orthopedic Surgery ResidentRothman InstituteThomas Jefferson University HospitalPhiladelphia, Pennsylvania, USA

Priscilla Ku Cavanaugh MD

Orthopedic Surgery ResidentDepartment of Orthopedic SurgeryDrexel University College of MedicineHahnemann University HospitalPhiladelphia, Pennsylvania, USA

Antonia F. Chen MD MBA

Assistant ProfessorRothman InstituteThomas Jefferson UniversityPhiladelphia, Pennsylvania, USA

Corey T. Clyde MD

Resident PhysicianDepartment of OrthopedicsUniversity at BuffaloBuffalo, New York, USA

Carl A. Deirmengian MD

Department of Orthopedic SurgeryRothman InstituteThomas Jefferson UniversityPhiladelphia, Pennsylvania, USA

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Rothman Institute Manual of Total Joint Arthroplasty: Protocol-Based Carex

Gregory K. Deirmengian MD

Associate ProfessorDepartment of Orthopedic SurgerySydney Kimmel Medical CollegeThomas Jefferson University Philadelphia, Pennsylvania, USA

Claudio Diaz-Ledezma MD

Staff Orthopedic SurgeonHospital Naval TalcahuanoTalcahuano, Chile, USA

Anthony J. DiMarino MD

Professor Thomas Jefferson University Philadelphia, Pennsylvania, USA

Edward J. Filippone MD

Clinical Associate Professor Thomas Jefferson University Philadelphia, Pennsylvania, USA

Seyedali R. Ghasemi MD

Orthopedic Research FellowRothman InstitutePhiladelphia, Pennsylvania, USA

Miguel M. Gomez MD

Research Fellow, Rothman Institute Thomas Jefferson University Philadelphia, Pennsylvania, USA

Robert P. Good MD

Clinical Associate ProfessorDepartment of Orthopedic SurgeryThomas Jefferson UniversityPhiladelphia, Pennsylvania, USA

Christina J. Gutowski MD MPH

Resident, Department of Orthopedic Surgery Thomas Jefferson University HospitalPhiladelphia, Pennsylvania, USA

Michael F. Harrer MD

Adult Reconstruction SurgeonDepartment of Orthopedic SurgeryRothman InstituteThomas Jefferson UniversityPhiladelphia, Pennsylvania, USA

Snir Heller MD

Fellow, Department of Orthopedic SurgeryRabin Medical CenterPetah Tikva, Israel

Bryan A. Hozack MD

ResidentDepartment of Orthopedic SurgeryRothman Institute Thomas Jefferson University HospitalPhiladelphia, Pennsylvania, USA

William J. Hozack MD

ProfessorDepartment of Orthopedic SurgeryRothman Institute Thomas Jefferson UniversityPhiladelphia, Pennsylvania, USA

Ronald Huang MD

Resident PhysicianDepartment of Orthopedic SurgeryThomas Jefferson University HospitalPhiladelphia, Pennsylvania, USA

H. Jane Huffnagle DO

Clinical ProfessorThomas Jefferson UniversityPhiladelphia, Pennsylvania, USA

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Suzanne Huffnagle DO

Clinical ProfessorThomas Jefferson UniversityPhiladelphia, Pennsylvania, USA

Fatih Kucukdurmaz MD

Associate ProfessorDepartment of Orthopedics and TraumatologyBezmialem Vakif UniversityIstanbul, Turkey

Eric J. Levicoff MD

Assistant Professor Sidney Kimmel Medical CollegeThomas Jefferson UniversityPhiladelphia, Pennsylvania, USA

Jess H. Lonner MD

Associate ProfessorDepartment of Orthopedic SurgeryRothman InstituteThomas Jefferson UniversityPhiladelphia, Pennsylvania, USA

Jorge Manrique MD

Fellow, Department of Orthopedic SurgeryRothman InstituteThomas Jefferson University Philadelphia, Pennsylvania, USA

Ryan Massimilla CCRP

Clinical Study ManagerRothman InstituteThomas Jefferson UniversityPhiladelphia, Pennsylvania, USA

Paul B. McKenna MD

Fellow, Rothman InstituteThomas Jefferson UniversityPhiladelphia, Pennsylvania, USA

Geno J. Merli MD

Professor Thomas Jefferson UniversityPhiladelphia, Pennsylvania, USA

Joshua J. Minori DO

Research Fellow, Department of Orthopedic ResearchRothman InstituteThomas Jefferson University HospitalPhiladelphia, Pennsylvania, USA

Philip Nimoityn MD

Clinical Assistant ProfessorDepartment of CardiologyThomas Jefferson University Philadelphia, Pennsylvania, USA

Alvin C. Ong MD

Clinical Instructor Assistant Professor Rothman InstituteThomas Jefferson University HospitalPhiladelphia, Pennsylvania, USA

Fabio Orozco MD

Associate ProfessorDepartment of Orthopedic SurgeryThomas Jefferson University Hospital Philadelphia, Pennsylvania, USA

Javad Parvizi MD FRCS

Professor, Department of Orthopedic SurgeryRothman InstituteThomas Jefferson UniversityPhiladelphia, Pennsylvania, USA

Contributors xi

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Rothman Institute Manual of Total Joint Arthroplasty: Protocol-Based Carexii

Ripal P. Patel MD

Research FellowDepartment of Orthopedic Surgery Rothman InstituteThomas Jefferson UniversityPhiladelphia, Pennsylvania, USA

Danielle Y. Ponzio MD

Resident, Department of Orthopedic SurgeryRothman Institute Thomas Jefferson University Philadelphia, Pennsylvania, USA

Zachary D. Post MD

Adult Reconstruction SurgeonRothman InstituteThomas Jefferson UniversityPhiladelphia, Pennsylvania, USA

James J. Purtill MD

Professor of Orthopedic SurgerySidney Kimmel Medical CollegeThomas Jefferson UniversityPhiladelphia, Pennsylvania, USA

Mohammad R. Rasouli MD

Resident Thomas Jefferson UniversityPhiladelphia, Pennsylvania, USA

Camilo Restrepo MD

Assistant DirectorClinical ResearchDepartment of OrthopedicsThomas Jefferson University Hospital Philadelphia, Pennsylvania, USA

Maryam Rezapoor MS

Research FellowRothman InstituteThomas Jefferson University Philadelphia, Pennsylvania, USA

Richard H. Rothman MD PhD

ProfessorDepartment of Orthopedic SurgeryThomas Jefferson University Philadelphia, Pennsylvania, USA

Eric S. Schwenk MD

Assistant Professor of AnesthesiologyThomas Jefferson UniversityPhiladelphia, Pennsylvania, USA

Alisina Shahi MD

Postdoctoral Research FellowDepartment of Clinical ResearchRothman InstituteThomas Jefferson UniversityPhiladelphia, Pennsylvania, USA

Julie L. Shaner MD

ResidentDepartment of OrthopedicsThomas Jefferson UniversityPhiladelphia, Pennsylvania, USA

Peter F. Sharkey MD

ProfessorDepartment of OrthopedicsRiddle Memorial HospitalMedia, Pennsylvania, USA

Eric B. Smith MD

Clinical Assistant ProfessorDepartment of Orthopedic SurgeryThomas Jefferson UniversityPhiladelphia, Pennsylvania, USA

Reza Mostafavi Tabatabaee MD

Joint Reconstruction FellowRothman Institute Thomas Jefferson UniversityPhiladelphia, Pennsylvania, USA

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Timothy L. Tan MD

Resident, Department of Orthopedic SurgeryThomas Jefferson UniversityPhiladelphia, Pennsylvania, USA

T. David Tarity MD

Adult Reconstruction and Joint Replacement FellowDepartment of Orthopedic SurgeryHospital for Special SurgeryNew York City, New York, USA

Lynda J. Thomson Pharm D

CACP

Advance Practice PharmacistDepartment of Pharmacy/SurgeryThomas Jefferson University HospitalPhiladelphia, Pennsylvania, USA

Eric H. Tischler BA

Research FellowRothman Institute Philadelphia, Pennsylvania, USA

Brian T. Urbani MS

Clinical Research CoordinatorDepartment of Orthopedic SurgeryRothman InstitutePhiladelphia, Pennsylvania, USA

Jessica R. Viola BS

Research Fellow, Rothman InstituteThomas Jefferson UniversityPhiladelphia, Pennsylvania, USA

Eugene R. Viscusi MD

ProfessorThomas Jefferson UniversityPhiladelphia, Pennsylvania, USA

Kristen Vogl DPT MBA

Director of Clinical ServicesAdministrator Musculoskeletal Service Line Thomas Jefferson University HospitalPhiladelphia, Pennsylvania, USA

Meng-Huang Wu MD

Attending PhysicianDepartment of Orthopedics Taipei Medical University HospitalTaipei, Taiwan

Je-Hyun Yoo MD PhD

Associate ProfessorDepartment of Orthopedic SurgeryHallym University Sacred Heart HospitalAnyang, South Korea

Benjamin Zmistowski MD

Resident Thomas Jefferson University Hospital Philadelphia, Pennsylvania, USA

Contributors xiii

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Orthopedic surgery and the delivery of care to patients have entered a new era. The financial pressure on the healthcare has compelled us to examine the cost-effectiveness of our practices and care protocols. The easy access to information on the Internet has generated well-read and fairly informed patients. The various grading systems for the doctors and the hospitals, together with the satisfaction scores from patients have all led to a rush to change the manner in which we deliver care. The recent changes in healthcare reimbursements and introduction of “bundling” in the US have further compelled the medical community to seek strategies that will allow delivery of high quality and cost-effective care. At our institution, we have been a believer in protocol-based care that allows efficient and cost-effective care. If these protocols are based on evidence, they provide further improvements in patient outcomes and serve to reduce cost. I am proud to present to you this book that summarizes many, if not all, the protocols that we have implemented at the Rothman Institute. The impetus behind writing this book is the numerous inquiries from colleagues and friends who have reached out to us asking for our protocols in various areas. We hope that having all of the institutional protocols will help our colleagues in the field to deliver greater care to their patients without having to reinvent the wheel. We realize that orthopedics is a fluid science, and many of these protocols will change in the future, if not changed by the time this book is printed. We will strive to keep the readers of this book informed of those changes by printing supplemental material in the future.

Javad Parvizi

Preface

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The completion of this book would not be possible without the immense help of many whose names do not appear in the author list. We would like to thank Katherine Huff and Krystal Golankiewicz for proofreading the chapters. Special thanks to the nurses and other residents on the ortho-pedic service who provided insight to the authors during the preparation of the chapters to ensure that the protocols were accurately presented.

Acknowledgments

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Rothman Institute Manual of Total Joint Arthroplasty: Protocol-Based Carexviii

Section 1: Preoperative Section Editors: Scot Brown, Javad Parvizi

1. Indications and Contraindications for Total Joint Arthroplasty 3Diana Bitar, James J. Purtill

2. Preoperative Radiographic Evaluation 11Camilo Restrepo, William J. Hozack

3. Consent: When and Where? 17Ryan Massimilla, Javad Parvizi

4. Perioperative Patient Evaluation 23Eric H. Tischler, Gregory K. Deirmengian

5. Additional Testing and Preoperative Consultation 27Julie L. Shaner, William J. Hozack, Philip Nimoityn

6. Management of Preoperative Medications 37Corey T. Clyde, Scot Brown

7. Prehabilitation for Total Knee Arthroplasty and Total Hip Arthroplasty 49Ripal P. Patel, Antonia F. Chen

8. Clinical Examination of the Hip 53Priscilla Ku Cavanaugh, Javad Parvizi

9. Clinical Examination of the Knee 57Priscilla Ku Cavanaugh, Javad Parvizi

Contents

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xix

10. Preoperative Nutritional Optimization 63Pouya Alijanipour, Matthew S. Austin

11. Smoking Cessation 67Pouya Alijanipour, Eric B. Smith

12. Perioperative Optimization of the Diabetic Patient 71Pouya Alijanipour, Matthew S. Austin

13. Optimization of the Patient with Cardiopathy 75T. David Tarity, James J. Purtill

14. Optimization of the Renal Failure Patient 81Timothy L. Tan, Edward J. Filippone, Antonia F. Chen

15. Optimization of Chronic Obstructive Pulmonary Disease 85T. David Tarity, James J. Purtill

16. Optimization of Sleep Apnea 89Mohammad R. Rasouli, Javad Parvizi

17. Optimization of Anemia 95Meng-Huang Wu, Javad Parvizi

18. Preadmission Testing and Preoperative Consultation 101Julie L. Shaner, William J. Hozack, Philip Nimoityn

19. Preoperative Templating 109Camilo Restrepo, Gregory K. Deirmengian

20. Implant Selection for Total Hip Arthroplasty 123Reza Mostafavi Tabatabaee, Carl A. Deirmengian

21. Implant Selection for Total Knee Arthroplasty 135T. David Tarity, Carl A. Deirmengian

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Section 2: PerioperativeSection Editors: Paul B. McKenna, Peter F. Sharkey

22. Intraoperative Deep Vein Thrombosis Prophylaxis 143Fatih Kucukdurmaz, William J. Hozack

23. Multimodal Pain Management in Total Knee Arthroplasty 147Priscilla Ku Cavanaugh, William J. Hozack

24. Multimodal Pain Management in Total Hip Arthroplasty 155Joshua J. Minori, William J. Hozack

25. Peripheral and Neuraxial Blocks for Analgesia After Total Joint Arthroplasty: Indications and Techniques 163Mohammad R. Rasouli, Eric S. Schwenk

26. Preoperative Antibiotics 173Antonia F. Chen, Javad Parvizi

27. Tranexamic Acid 179Mohammad R. Rasouli, Javad Parvizi

28. Intraoperative Steroid Administration 187Diana Bitar, Paul B. McKenna, Matthew S. Austin

29. Anesthetic Techniques in Total Joint Arthroplasty: Neuraxial Anesthesia 191Mohammad R. Rasouli, Suzanne Huffnagle, H. Jane Huffnagle

30. Anesthetic Techniques in Total Joint Arthroplasty: General Anesthesia 197Mohammad R. Rasouli, H. Jane Huffnagle, Suzanne Huffnagle

31. Skin Preparation 203Corey T. Clyde, Javad Parvizi

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Contents xxi

32. Tourniquet Use in Total Knee Arthroplasty 209Christina J. Gutowski, Peter F. Sharkey

33. Operating Room Universal Precautions 217Pouya Alijanipour, Eric B. Smith

34. Surgical Hand Antisepsis Practices 221Danielle Y. Ponzio, Antonia F. Chen

35. Operating Room Traffic 227Eric H. Tischler, Paul B. McKenna, Matthew S. Austin

36. Draping 233Pouya Alijanipour, Richard H. Rothman

37. Approaches to the Hip: Direct Anterior 237Reza Mostafavi Tabatabaee, Paul B. McKenna, William J. Hozack

38. Approaches to the Hip: Direct Lateral 243Fatih Kucukdurmaz, Paul B. McKenna, Richard H. Rothman

39. Approaches to the Hip: Posterior 249Christina J. Gutowski, Robert P. Good

40. Medial Parapatellar Approach for Total Knee Arthroplasty 255Paul B. McKenna, Peter F. Sharkey

41. Subvastus and Midvastus Approach for Total Knee Arthroplasty 261Seyedali R. Ghasemi, Jess H. Lonner

42. Unicompartmental Knee Arthroplasty 265Je-Hyun Yoo, Jess H. Lonner

43. Patellofemoral Arthroplasty 273T. David Tarity, Jess H. Lonner

44. Total Hip Arthroplasty in Patients with Metabolic Bone Disease 279T. David Tarity, William J. Hozack

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Rothman Institute Manual of Total Joint Arthroplasty: Protocol-Based Carexxii

45. Total Hip Arthroplasty in Protrusio Acetabuli 283Reza Mostafavi Tabatabaee, Matthew S. Austin

46. Total Hip Arthroplasty in Patients with Proximal Femoral Deformity 289Reza Mostafavi Tabatabaee, Matthew S. Austin

47. Total Knee Arthroplasty for Patients with Severe Deformity 295Jorge Manrique, Fabio Orozco

48. Antibiotic Impregnated Cement 303Christina J. Gutowski, Javad Parvizi

49. Computer-Assisted Total Knee Arthroplasty 309Snir Heller, William J. Hozack

50. Patient-Specific Instrumentation 313Reza Mostafavi Tabatabaee, Javad Parvizi

51. Management of Vascular Complications: Hip 317Snir Heller, Peter F. Sharkey

52. Management of Vascular Complications: Knee 321Diana Bitar, Paul B. McKenna, Peter F. Sharkey

53. Surgical Drains 331Alisina Shahi, Richard H. Rothman

54. Wound Closure 337Miguel M. Gomez, Zachary D. Post

55. Urinary Catheter in Primary Total Joint Arthroplasty 341Priscilla Ku Cavanaugh, Alvin C. Ong

56. Surgical Dressing in Total Joint Arthroplasty 345Eric H. Tischler, Peter F. Sharkey

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Contents xxiii

57. Postoperative X-rays (Hips and Knees) 349Camilo Restrepo, Alvin C. Ong

58. Heterotopic Ossification Prevention 357Camilo Restrepo, Zachary D. Post

Section 3: Postoperative ManagementSection Editors: Antonia F. Chen, Gregory K. Deirmengian

59. Operative Note Dictation in Total Joint Arthroplasty 363Claudio Diaz-Ledezma, Javad Parvizi

60. Postoperative Fluid Management 369Meng-Huang Wu, Javad Parvizi

61. Venous Thromboembolism Prophylaxis for Total Joint Arthroplasty 375Timothy L. Tan, Richard H. Rothman

62. Risk Stratification for Venous Thromboembolism After Total Joint Arthroplasty 383Maryam Rezapoor, Ronald Huang, Javad Parvizi

63. Sleeping Aids After Total Joint Arthroplasty 391Brian T. Urbani, Fabio Orozco

64. Postoperative Gastrointestinal Complications 395Danielle Y. Ponzio, Anthony J. DiMarino

65. Routine Postoperative Laboratory Investigations 401Je-Hyun Yoo, Jess H. Lonner

66. Postoperative Antibiotic Prophylaxis 405Danielle Y. Ponzio, Eric B. Smith

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67. Wound Care and Dressings 411Snir Heller, James J. Purtill

68. Transfusions 415Danielle Y. Ponzio, Javad Parvizi

69. Fever Management 421Je-Hyun Yoo, Eric J. Levicoff

70. Oxygen Desaturation Management 427Jessica R. Viola, Antonia F. Chen, William J. Hozack

71. Altered Mental Status and Postoperative Neurologic Abnormalities 433David S. Casper, Michael F. Harrer

72. Weight-Bearing After Total Joint Arthroplasty 439Diana Bitar, Peter F. Sharkey

73. Management of Urinary Retention After Total Joint Arthroplasty 445Jenny Cai, Carl A. Deirmengian

74. Management of Cardiac Arrhythmias 449Snir Heller, Philip Nimoityn

75. Management of Diagnosed Deep Vein Thrombosis 455Geno J. Merli, Lynda J. Thomson

76. Management of Diagnosed Pulmonary Embolism 465Geno J. Merli, Lynda J. Thomson

77. Physical and Occupational Therapy After Total Knee Arthroplasty 473Joshua J. Minori, Kristen Vogl

78. Physical and Occupational Therapy After Total Hip Arthroplasty 479Joshua J. Minori, Kristen Vogl

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Contents xxv

79. Discharge Destination: Rehabilitation vs Home 485Ryan Massimilla, Kristen Vogl

80. Home Physical Therapy After Total Joint Arthroplasty 489Jorge Manrique, Kristen Vogl

81. Discharge Pain Medications 497Joshua J. Minori, Eugene R. Viscusi

82. Activity Modification After Total Hip Arthroplasty 503Reza Mostafavi Tabatabaee, Richard H. Rothman

83. Continuous Passive Motion for Rehabilitation After Total Knee Arthroplasty 509Seyedali R. Ghasemi, Richard H. Rothman

84. Follow-Up Times and Goals After Total Joint Arthroplasty 513Ryan Massimilla, Fabio Orozco

85. Antibiotic Prophylaxis for Minor Procedures After Total Joint Arthroplasty 517Fatih Kucukdurmaz, Eric J. Levicoff

86. Restarting Medications 523Corey T. Clyde, Robert P. Good

Section 4 ComplicationsSection Editors: Antonia F. Chen, William J. Hozack

87. Management of Wound Drainage After Total Joint Arthroplasty 533Alisina Shahi, James J. Purtill

88. Postoperative Blister 539Snir Heller, William J. Hozack

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Rothman Institute Manual of Total Joint Arthroplasty: Protocol-Based Carexxvi

89. Postoperative Infection Investigation 543Benjamin Zmistowski, Javad Parvizi

90. Management of Acute Infection: Hip 549Benjamin Zmistowski, Antonia F. Chen

91. Management of Acute Infection: Knee 553Fatih Kucukdurmaz, Antonia F. Chen, Javad Parvizi

92. Management of Chronic Infection 559Benjamin Zmistowski, Antonia F. Chen

93. Management of Dislocated Hip: Early vs Late 567Diana Bitar, William J. Hozack

94. Management of Intraoperative Fractures During Total Hip Arthroplasty 579Alisina Shahi, James J. Purtill

95. Management of Intraoperative Fractures During Total Knee Arthroplasty 583Alisina Shahi, James J. Purtill

96. Management of Postoperative Periprosthetic Hip Fractures 589Diana Bitar, Gregory K. Deirmengian

97. Management of Postoperative Periprosthetic Knee Fractures 599Julie L. Shaner, Alvin C. Ong

98. Management of the Swollen Limb in the Early Postoperative Period 607Miguel M. Gomez, Zachary D. Post

99. Management of Residual Leg Length Discrepancy After Total Hip Arthroplasty 611Bryan A. Hozack, William J. Hozack

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Contents xxvii

100. Management of Stiffness After Total Knee Arthroplasty 617Eric B. Smith, Jenny Cai

101. Management of Painful Total Knee Arthroplasty 621Benjamin Zmistowski, Peter F. Sharkey

102. Management of Neurologic Deficit: Hip 627T. David Tarity, Fabio Orozco

103. Management of Neurologic Deficit: Knee 633T. David Tarity, Fabio Orozco

Index 637

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Clinical Examination of the KneePriscilla Ku Cavanaugh, Javad Parvizi

Chapter

9

Rothman ProtocolAll patients undergo a thorough medical history and knee examination. Clinical examination of the knee consists of inspection, palpation, motor testing, neurological testing, and in certain cases determined by the clinician, other special tests. The hip is also examined to rule out hip pathology as the culprit for symptomatology.

Knee Examination AlgorithmInspectionObserve the patient walking and note the presence of a limp, asymmetry, gait or other abnormalities. Upon closer inspection, look for edema, discoloration, lacerations, scars, ecchymosis, muscle atrophy, or other abnormalities. Next, assess limb alignment with the patient standing making sure to note any genu varum, genu valgum, or genu recurvation.

PalpationBegin palpation of the knee joint by assessing its temperature, using the surrounding areas and contralateral leg for comparison. Infection or an acute knee injury may lead to a warm knee. Locate and palpate the tibial tuberosity, patella, and joint line. On both sides, palpate below the patella for swelling. Patellar subluxation should

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Rothman Institute Manual of Total Joint Arthroplasty: Protocol-Based Care58

be noted. Tenderness at the joint line may indicate intra-articular pathology such as arthritis. While moving the patient’s knee, feel for patellar tracking and crepitus. Crepitus indicates arthritis. Locate and palpate the medial and lateral meniscus noting any tenderness because it may indicate a tear. On the upper medial aspect of the tibia, locate the pes anserine bursa, palpate for any pain, effusion, or thickening. Assess stability of the collaterals by stabilizing the distal femur and applying varus and valgus stress to the tibia at full extension and with the knee flexed to 20°. Stability of the menisci and cruciates are tested by specific examinations (discussed in Table 9.3).

Motor AssessmentEvaluate the patient’s active and passive range of motion (Table 9.1).

Neurocirculatory AssessmentAssessment includes a pertinent vascular examination followed by sensory, muscle, and reflex testing.

Vascular ExaminationBegin with the patient’s knee relaxed in flexion, palpate for the popliteal pulse located deep behind the knee. Next, distally palpate the dorsalis pedis and posterior tibialis

Table 9.1. Range of motion assessment (ROM) components for the knee

Knee Exam Patient PositioningNormal

ROM up to

Internal/external rotation

Seated, femur stabilized, tibia rotated

10°

Flexion Supine, knee bent, heel towards buttocks

135°

Extension Supine, straighten knee from bent position

0°

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Clinical Examination of the Knee 59

bilaterally for strength and symmetry. Note that absence of hair or skin discoloration may signify poor circulation.2 If abnormalities are found and peripheral vascular disease (PVD) is suspected, ankle-brachial indexes (ABI) should be obtained using Doppler ultrasound. It is crucial to identify PVD patients, because PVD is a relative contraindication to total knee arthroplasty. An ABI of 0.9–1.3 is considered normal; if less than 0.9, the patient may have elevated risk of arterial complications and should be referred to a vascular surgeon. An ABI less than 0.5 indicates severe ischemia and an angiogram is recommended.3

Sensation TestingTest sensation in dermatomal distribution and assess the different sensory modalities: temperature, sharp touch, light touch, vibration, and proprioception.

Muscle TestingBilaterally assess power of muscle groups, using the contralateral limb for comparison. Maneuvers are shown in Table 9.2.

Reflex TestingBoth the patellar reflex (L2, 3, 4) and ankle reflex (S1) should be assessed bilaterally.

Other Common/Special TestsAdditional individual knee components are tested with other specific tests. Maneuvers for key tests are described in Table 9.3.

Table 9.2. Muscle examination components for the knee

Exam Muscles Involved

Extension Primary: quadriceps femoris

Flexion Primary: Hamstring muscles (biceps femoris, semitendinosus, semimembranosus)

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Rothman Institute Manual of Total Joint Arthroplasty: Protocol-Based Care60

Tabl

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olla

tera

l lig

amen

t (M

CL)

Supi

ne p

atie

nt, s

ecur

e th

e an

kle

and

push

med

ially

aga

inst

kne

e an

d la

tera

lly a

gain

st ip

sila

tera

l ank

le

Gap

in m

edia

l bor

der o

f kn

ee jo

int;

pain

MCL

dam

age

Late

ral c

olla

tera

l lig

amen

t (LC

L)Su

pine

pat

ient

, sec

ure

the

ankl

e an

d pu

sh la

tera

lly a

gain

st k

nee

and

med

ially

aga

inst

ipsi

late

ral a

nkle

Pain

LCL

dam

age

Dra

wer

test

Supi

ne p

atie

nt w

ith k

nee

90° fl

exed

, sl

ide

prox

imal

tibi

a an

terio

rly (a

) or

post

erio

rly (b

); co

mpa

re to

uni

njur

ed

knee

(a) A

nter

ior t

rans

latio

n(b

) Pos

terio

r tra

nsla

tion

(a) A

CL in

jury

(b) P

CL in

jury

*Not

e: In

tegr

ity o

f AC

L no

t pre

serv

ed

durin

g TK

A

Jayp

ee B

rothe

rs

Clinical Examination of the Knee 61

Lach

man

Supi

ne p

atie

nt w

ith k

nee

flexe

d 20

°–30

°, an

terio

r for

ce a

pplie

d to

pr

oxim

al ti

bia

Laxi

ty o

f tib

ia, t

ibia

pu

lled

forw

ard

ACL

defic

ienc

y

Pivo

t shi

ft

Supi

ne p

atie

nt, k

nee

exte

nded

, IR,

ap

ply

valg

us fo

rce

and

flex

knee

Late

ral t

ibia

l pla

teau

sh

ifts

post

erio

rlyAC

L de

ficie

ncy

McM

urra

y Su

pine

pat

ient

, flex

ed h

ip a

nd k

nee,

pa

lpat

e la

tera

l joi

nt s

pace

, and

with

ot

her h

and

alte

rnat

e be

twee

n IR

and

ER

of f

oot

Pain

(with

men

isca

l sn

ap o

r cre

pitu

s)M

edia

l or l

ater

al

men

isca

l tea

r/le

sion

Squa

t tes

tSq

uats

by

patie

nt, f

eet a

nd le

gs

alte

rnat

ing

betw

een

inte

rnal

and

ex

tern

al ro

tatio

n fo

r eac

h sq

uat

(a) M

edia

l pai

n(b

) Lat

eral

pai

n(a

) Lat

eral

men

isca

l te

ar(b

) Med

ial m

enis

cal

tear

Jayp

ee B

rothe

rs

Rothman Institute Manual of Total Joint Arthroplasty: Protocol-Based Care62

References 1. Parvizi J, editor. Orthopaedic examination made easy. New

York: Churchill Livingston Elsevier; 2006. pp. 89–103. 2. Garabekyan T, Oliashirazi A, Winters K. The value of

immediate preoperative vascular examination in an at-risk patient for total knee arthroplasty. Orthopaedics. 2011;34(1):52.

3. Tria AJ Jr. Clinical examination of the knee. In: Scott WN, editor. Insall & Scott surgery of the knee. 4th ed. Philadelphia, PA: Churchill Livingstone Elsevier; 2006; pp. 86–9.

4. Farber NJ, Chen AF, Klatt B. Preoperative clinical evaluation. In: Parvizi J, editor. The knee: reconstruction, replacement, and revision. Brooklandville, MD: Data Trace Publishing; 2013; pp. 1–9.

Jayp

ee B

rothe

rs