Intro to Adult Reconstruction Matt Dietz Ben Frye

Intro to Adult Reconstruction Matt Dietz Ben Frye Adam Klein

Overview • Adult Reconstruction Encompasses – Primary total hip and knee replacement – Partial knee replacement – Revision total hip and knee replacement – Treatment of infected hip and knee arthroplasty – Repair of peri-prosthetic fractures

Conference Schedule • Didactic lectures – Tuesday 0645 in the learning center • Case conference – Fridays at 0630 in the learning center

Reading Resources • OKU 4 Adult Reconstruction • www. wvucjr. wordpress. com – Articles and past powerpoints • Campbells Operative Orthopaedics

Post Op Orders • Joint Center Post Op Orders – Specify diet – Specify weight bearing and activity restrictions • PT/OT order – weight bearing status is linked • Activity order – Select VTE prophylaxis – ASA vs Lovenox vs Arixtra – Select antibiotic prophylaxis – Resume essential home meds

SCIP Protocol • Surgical Care Improvement Project – A subset of national hospital quality measures – Concerns prophylactic antibiotics, VTE prophylaxis, continuation of Beta blocker and Foley catheter retention

SCIP – Foley Catheter – Foley MUST be removed POD #2 (or reason for retention documented) – Foley usually removed POD #1 unless • Patient had difficult Foley insertion • Risk for retention is high (elderly man with BPH and limited mobility) • Need to closely monitor urine output

SCIP – Prophylactic Antibiotic • Prophylactic antibiotics must be administered within 1 hour of cut time AND discontinued within 24 hours of end time – First post op dose given at completion of surgery • This is time zero – Two more doses follow

SCIP – Prophylactic Antibiotic • 1 st generation cephalosporin (cefazolin) – Vanco reserved for MRSA carriers or those at risk of MRSA (health care workers, prior history) • Needs to be started 2 hours before surgery – Clinda 900 mg for those with true anaphylaxis with Beta lactams

Antibiotics – To Hold or Hold Not • Hold – When infection is OBVIOUS and there is need to obtain deep cultures • eg, draining sinus over total joint • Hold Not – At second stage of 2 stage exchange when reimplant is probable

Antibiotics – 24 hours and beyond • Reimplants pending operative cultures – generally 48 hours • For obviously infected cases: – Vanco 15 mg/kg Q 12 and Cefepime 2 gm Q 12 is typical regimen

SCIP - VTE • VTE prophylaxis must be commenced within 24 hours of end time • Chemo-therapeutic options – ASA 325 daily – Lovenox 30/40 daily – Arixtra 2. 5 mg daily – Xarelto 10 mg daily – Coumadin dose adjusted

VTE Prophylaxis • Low risk patients (no history, full WBAT) – ASA 325 mg daily for 6 weeks – TEDs for 4 weeks – Pumps for 2 weeks • Moderate risk (family history, partial WB) – Lovenox 40/30 once daily for 3 weeks – Arixtra 2. 5 mg daily for 3 weeks • High risk (personal history) – Coumadin or Xarelto for 6 weeks

Rounds • Dressing change – Generally POD #2 • Drains – 1 joints – POD #1 – Rev joints - <30 cc’s per shift or POD #2 – Infected joints - <30 cc’s per shift

Rounds • IVF’s – Saline lock POD #1 or 2 – Retain for hypotension, poor p. o. intake, bump in creatinine • Foley – Remove POD #1 or 2 – Retain for poor mobility, need to closely watch u. o. , difficult foley insertion

Hospital Documentation • Anemia after surgery – Document “acute post surgical blood loss anemia” for Hgb < 11. 5 – If anemia is chronic, say so – sometimes it’s both • Document labs (. lasthemogram and. lastbmp) – Specify abnormalities and treatment needed

Office Documentation • Specific documentation required for joint replacement candidates – Denied claims and “clawback” results if documentation does not support need for joint replacement

Office documentation • Chief complaint – Pain severity, instability, mechanical symptoms • How long have symptoms been present • Specific activity limitations – Work, recreation, ADL’s – Distance patient can walk • Walking aids – cane, walker, wheelchair, etc.

Office Documentation • Patients must have failed conservative care (or document reason why these are contraindicated) – NSAIDs – 3 months of physical therapy – Intra-articular injections – Bracing – Weight loss

Office Documentation • Document exam findings – ROM – Deformity – Limp – Swelling – Tenderness – Crepitus

X-ray Documentation • Must document specific radiographic features of arthritis – E. g. , osteophytes, joint space narrowing, subchondral sclerosis and cysts, deformity

X-ray Documentation • Incorrect – “x-rays of the knee shows severe arthritis” • Correct – “x-rays of the knee shows severe arthritis as evidenced by joint space narrowing, subchondral sclerosis, subchondral cyst formation, osteophytosis and varus deformity”

Office Documentation • Impression – Severe DJD knee or hip • Plan – Summarize justification for joint replacement given severity of symptoms, failure of conservative care, and no other reasonable conservative or surgical option

Office Documentation • Correspondence – Always cc referring physicians and other physicians • It’s the polite thing to do • Communication between doctors is vital • It fosters future referrals

Thank You Sir John Charnley John Insall