Can you answer our FREE Question of the Day? A 72-year-old female presents to the clinic failing nonoperative management of left tri-compartmental osteoarthritis. She undergoes an uncomplicated total knee arthroplasty and does well postoperatively (Figures A & B). Three years later, she falls down her stairs at home and undergoes surgery for her distal femur periprosthetic fracture at an outside facility. She returns to your clinic approximately 3 months later complaining of continued pain requiring prolonged narcotic use. She has remained on partial weight-bearing status since her most recent surgery but endorses feelings of knee instability/buckling during physical therapy sessions. The incision appears healed and there is a moderate effusion with a notably limited range of motion. Her most recent radiographs are shown in Figures C & D. Which of the following is the most appropriate next step in management? 1. Initiate progressive strength training and a return to walk protocol with physical therapy 2. Order inflammatory labs and perform a joint aspiration with synovial fluid analysis 3. Refer the patient to a durable medical equipment provider for a bone stimulator 4. Perform hardware removal, deformity correction, and revision open reduction internal fixation 5. Perform hardware removal and conversion to distal femur replacement QID: 218160 Comment your answer below, then check to see if you got it correct by clicking the link below to see the answer & explanation. https://bit.ly/4hQU2h0 #orthopedics #orthopedicsurgeon #orthopaedics #orthopaedic #orthopedic #ortholife #orthobullets #orthoresidents #orthoresident #orthoresidency #medicalschool #medicalstudent #medstudent #doctor #physician
2 first and then 5 as it probably will provide the best long term stability of the knee.
2 and then 4. There was plenty of distal bone and fracture tried to heal but the surgeon did not provide the optimum osteosynthetic environment for bone healing to progress. Revise to a nail plate construct and immediate full weight bearing.
Rule out infection., if OK, go for step4 with eventually addition of cancellous bonegrafts. If during surgery there is doubt on the quality of de condyles, or if it is technically not evident to put in sable screws, go for 5.
CT, if sufficient bone stock distal I would go for option 4, if not option 5
Start with 2, talk with patient regarding 4 and 5. I would lean toward 5.
2 then 5
4
Orthopaedic Trauma Surgeon at Tulsa Bone & Joint Associates
2moI don’t think “appropriate” is a good word in a question. That’s leading to subjectivity. 4/5 are both good options depending on what the patient wants. They each carry their own risk. It depends on activity level etc. would have to investigate further to see if there is loosening of the prosthesis. Some would argue that 2 is correct because they want to work up every failure case for infection, and that’s not wrong.