Author: The Knee Book-A Guide to the Aging Knee /Ortho Surgeon in
#SoCal
/ Meditation Teacher / Opinions my own / PODCAST: TKA Tips and Pearls / PGY-24
My podcast on TKA, indications, patient optimization & step by step techniques of the approach, releases, bone cuts and balancing.
#totalknee
#orthopedic
I shared something personal yesterday on LinkedIn
After 20 years as an orthopedic surgeon I began having panic attacks. It ultimately led to a mental health crisis and a diagnosis of major depression. I had to take a leave of absence to get help.
Why be so open & vulnerable?
Insomnia, panic attacks, decreased appetite, loss of motivation, feeling of hopelessness
I got professional help, enrolled in cognitive behavioral therapy, took an MBSR class, continued meditating, focused on exercise, nutrition and sleep.
I’m about to return to work part-time
Burnout & moral injury is at an all time high. I wanted to let those who may be suffering in silence that they are not alone.
Key causes: EMR, staffing shortages, insurance companies, patient demands, administrative burdens, a surgical complication.
What were the red flags?
@DrPayItBack
I remember a young patient who was being seen along with her was her mother.
It was the patient who asked me what that was ?
Me: your belly button ring
Her mom: WHAT BELLY BUTTON RING!
Me to the patient: you asked
Ortho Tips for knee pain for IM, FP
1.Don’t order knee MRI in pts >50 (except for fx, tumor)
2.Get WEIGHT BEARING x-rays
3.Discuss wt loss in overweight pts
4.Rec home exercises
5.Don’t rx narcotics
6.Optimize health (controlled DM, quit smoking)prior to referring for surgery
Not a very scientific way of evaluating wear. Expired poly given to my dog as a chew toy each for a week. Significant differences in wear due to teeth and chewing.
Congratulations to all of you who matched in orthopedics. Great to see more women coming into the specialty. Cheers to all!!
#orthotwitter
#orthomatch2022
All of the negatives of healthcare aside. It is still a wonderful feeling to meet someone in pain, on a walker with a failed TKA and be able to fix their knee and watch them walk back in unassisted with a huge smile.
When a patient presents to the clinic w/this X-ray. That cup should be easy to remove. Anyone else ever see that stem fracture like that? Had to ETO to get it out.
@realDrHartzler
I have many analogies. Most common: If a normal knee is a 10/10. A TKA at best will be an 8. If you are a 7 right now you probably won’t be happy w/surgery and months of rehab to improve 1 point. But if you’re a 4 and then go to an 8, that is a 100% improvement.
Really wish their was a code for complex primary TKA when you have to use a stem and augment. Anyone try to use revision one part to account for the time and cost of the stem and augment?
#orthotwitter
#MedTwitter
Neat looking at my progression of primary stems during my years in practice. TMZF, secure fit plus (Japanese version w/V40), Accolade II, Echo, Actis (not pictured), Aveneir. Each has a technical pearl for implantation, pros and cons. Change over time was for multiple reasons.
I think my life would be easier if PCPs would order weight bearing xrays, try at least one week of an OTC medication and start patients with a BMI over 35 on a weight loss program prior to sending them to me for a surgical consult. Is that too much to ask?
@stewartwjames
So true. Informed consent is very personalized. It needs to be in a way that patients understand based on their background, education and level of understanding. This definitely leads to more informed patients.
@denehy1
Getting worse bordering on criminal. I had peer to peer for not documenting noise in a knee for TKA. I had to explain that crepitations is the medical term for noise (like rice crispies)
@generalorthomd
@patel_doctor
I had a knee recently denied because, “clinical documentation did not mention abnormal noise from the knee.” Seriously. I had to resend my note which stated moderate crepitations, circle the word and include what the definition of crepitations were. Then it was approved.
@MSWSchnoodle
@Millennial__MD
I think the similarities are in waking up early going to work and making something that makes others feel better. Nothing like fresh baked bread!
@TheBlondeRN
When I worked in an ER in college nurses taught me everything. As an intern and a resident nurses saved my butt on multiple occasions. Now the nurses I have the privilege to work with are equally important in the care we provide our patients. I couldn’t do my job without them.
I debated about sharing my mental health crisis but the overwhelming positive support was beyond anything I could have imagined. Many of you shared your own struggles. I hope this is just a start to eradicate the stigma of getting help for mental illness. I have been adding
I have had a bunch of valgus knees lately and this episode contains a lot of what I share with our fellows when approaching these surgeries
#orthotwitter
@sahilsanghavi
I tell pts if a perfect normal knee is a 10 a great TKA is at best an 8. If you are a 4 that can be a 100% improvement but if you expect a 10 you’ll never be happy. If you are a 7 and go to an 8 you’ll probably not be happy to move up only 1 point.
My school loan balance is $0.00. I am happy but I really thought I would be more excited, maybe even a congratulations from the lender. After derferment/forbearance during training I began paying it off in 2006. I hope for future students, education will be more affordable.
One of the coolest gifts I received from a patient who was an artist. He said they were taught to draw skeletons, then skinned cadavers before people to have a better understanding of the skeletal & muscular shape of the human body.
@JArthroplasty
@AAHKS
@DrChadKrueger
We keep coming up with answers (nav, psi, sensors, robots, mechanical, kinematic and anatomic alignment) but we still don’t know the right questions on how to improve on the 15% or more of unhappy patients after TKA.
A thread. I’m a knee guy but as an arthroplasty surgeon I also do hips, the posterior way. I have a number of tips that trainees like.
1. Check leg length. Know what the patient feels, check X-ray, check supine then recheck once in lat position…
To all of the patients with MRIs and/or non weight bearing X-rays from your PCP or the ER. Yes, you still need new X-rays today with you standing, so we can assess your alignment and arthritis. Thank you, and sorry for any inconvenience or added radiation exposure.
#orthotwitter
@patel_doctor
I get it if BMI is over 40 with no attempts at weight loss. And I get it if BMI < 18. But, 32. A denial by the insurance company is ridiculous and they should be held responsible for delay of care
Move it or lose it. Many patients with
#arthritis
find with regular gentle exercise they feel better.
#pain
may improve. Good tips from
@CreakyJoints
@drsebheaven
Waste of time
Waste of resources
Waste of money
Waste of stress&anxiety for the patient when they read report
Waste of time explaining to the patient why they need an X-ray even though they have an MRI
Med schools&training programs need to do better
Only let Ortho order MRIs
Patient has $100 copay for mri
Claustrophobic and needs sedative medication
Anxiety b/c report makes it sound terrible
Me: gently explain it is arthritis
Inside I feel terrible b/c they wasted time and money for an unnecessary test ordered by the PCP
Don’t order MRIs for DJD
Sir John Charnley is a legend and still helping patients with his work. A mentor gave me this book, which is a must read for any arthroplasty surgeon.
#orthotwitter
#medtwitter
@MrsPA_C
So sad. I’m not sure people realize how
#COVID19
will affect access to healthcare for years to come. Loss of
#HCW
from death by COVID, suicide and leaving the profession due to burnout, plus those not enrolling or dropping out of school.
@kiswanson
@Aetna
I have always believed it should be billable as a phone visit based on time. 90% of the time I do not speak with an orthopedic surgeon and 100% of the time the doc on the phone knows nothing about the case. At least have the person that denied patient care get on the phone.
Many knee systems have these stubby’s that you remove when adding a stem for a revision. I started a collection. What can we as an orthopedic community recycle these into to help someone or something or somewhere? I’m sure world wide many get tossed in the trash.
CR vs PS has been a long ongoing debate in the world of TKA.
I am so much more curious about how? mechanical, anatomic or kinematic? when it comes to knees.
Which is best for all, or is one best for a particular knee? I think prospective data collection w/AI could answer the ?
After years of static spacers then a transition to cement molded articulated spacer this 2 stage implant protocol is my current practice and works extremely well
Infection after a total knee
#arthroplasty
is one of the most challenging complications. This protocol of two-stage exchange for infected knee arthroplasties with an articulating spacer & using new primary knee implants achieves adequate
#infection
control
@MGastorf
Talk to someone. Let them know how you feel. Consider part time or an LOA. You must take care of your physical and mental health first. We all tend to put patients first but that can negatively affect your health and your ability to care for others. Thanks for sharing. 🙏
@dubiel_matt
I head into the room after it is clean. Help open trays, check for holes and get set up with positioners, tourniquet, etc. I feel the team works harder and faster when you are there. More importantly you can see first hand what can change to make the turnover more efficient.
Another study in
@JArthroplasty
in 2010 showed that patients felt surgeons were paid 10times more than they actually received for performing total joints&were surprised when they found out how low payments were
The result was quite remarkable in that every single specialty in Orthopaedic Surgery Has seen diminished reimbursement over this period, with the largest decrease seen in Adult Reconstruction for
#HipReplacement
and
#KneeReplacement
.
Congrats to Drs. Mombell, Udall, Squires, and Vlahu for matching with us. SCMG Adult Lower Extremity Reconstruction Fellowship Class of 2024-25. We are looking forward to a great year!
@NaanDerthaal
Yep saw a valgus knee on Friday, same thing but after the NWB “mild OA” X-ray they got an MRI. And I get to explain why they needed a WB X-ray that shows bone-on-bone. It’s the orthopedic groundhogs day.
@Maheen_Nadeem22
@orthobullets
Still have mine on the bookshelf. I hope my podcast is a benefit to residents now. Lots of episodes on classifications and for quick reference they are written out in the show notes with references.
I don’t mind it so much when my brain wakes me up in the middle of the night thinking about a patient.But when it’s b/c some stupid hospital committee of non-doctors blocks the FREE trial of a technology in the OR it drives me nuts.We promote research&education but they stop both
@arghavan_salles
Yep, hold their hand and rub their forearm as the propofal runs in. They may not remember but I have to believe it helps in the moment.
It may seem obvious to some but I see people struggle w/hemi’s. Approach. Neck cut. Expose acet. Remove head. Size acet. Broach. Trial. Balance. Implant. People struggle to get the head out before cutting the neck. Why?
There are a lot of steps in a TKA. Irrigation should be part of the algorithm. I hear many who hang 2L and at the end realize they haven’t irrigated. I use 500cc after the bone cuts, 500 prior to cementing, 500 prior to capsule closure and the final 500 during layered closure.
The Knee Book - A Guide to the Aging Knee is available on
@amazon
I wrote this for patients with
#arthritis
, to answer common questions, to explain symptoms and treatments, and review the expectations surrounding total
#knee
replacement surgery.
@bleedingedgedoc
was very interesting, informative and scary all at the same time. I witnessed the metal issues in total hips. New does NOT indicated improved until its old, tried and TESTED.
@JennaBernstein7
That’s how M&M start, 50 yo with BMI 46 and poor surgical candidate underwent a THA...
Help the patient. starts with metabolic optimization. You can always make them worse w/surgery, if you can help the patient first, surgery will help them in the near future.
It all began March 2020 during
#Covid
. I had an outline for a podcast on TKA (basically the whole first season). It’s now up to 91 episodes and almost 10K downloads. Be sure to check it out and subscribe if you haven’t listened yet.
#orthotwitter
If you are a PT or home health RN please don’t tell a patient they have an infection or a blood clot. Inform them and the doc that they have ‘finding’ (swelling, redness, drainage, etc) and let us make the diagnosis.
@karenerrichetti
1. I’m a
#SoCal
Total knee surgeon, husband, dad of 2 and originally from
#Philly
2. Knees, exercise and healthy living
3. I used to jump out of airplanes (on purpose) & I’m an aspiring author
@DBelardoMD
My favorite way for a cup of coffee (and the simplest) - the Moka pot by Bialetti! Use it at home or camping over the stove. The perfect between a cup of coffee and an espresso cup of goodness
We had talked about distal stem pain and varus remodeling. This was a pt w/a number of comorbidities w/pain and hot bone scan only at the tip of stem. Added Lateral allograft with anterior plate. Last X-ray is 11 years post op and pain free.
@EasyOrtho1
Covid resulted in lighter schedules. I like having the ability to spend more time to with a patient. My patients like that I spent so much time with them. In a productivity system I don’t like being informed that I’m not seeing enough patients.
@EdinburghKnee
I’ve been using it for hip fx for years. Actually given on admission not at surgical start time. I saw a reduction in anemia in that 24 hour interval prior to surgery but don’t have enough numbers to publish or prove. IMO
Remember the clackers toy? One of my silly projects during the covid shutdown. No fractures with repeated use-a home wear simulator.
@ceramtec
#orthotwitter
Kudos
@meganranney
&
@JosephSakran
&
@TIME
This states the coming collapse of healthcare due to the continued high pressure demands on an already burdened care workers are suffering now,more patients will suffer going forward due to limited staff&supplies
@ProfDavidHunter
I’m hoping my new book can make a tiny dent in preventing the unnecessary MRI. I hope patients understand,but also PCPs if they read it. I explain why WB X-rays are needed and why MRIs are rarely necessary.( fx,tumor,inf,ON)
Not sure if others have used this example. I started referring to looking for a concentric mortise of the reamer in the acetabulum to explain to our fellows when it is eccentric and they could be at risk of reaming out the wall. Common w/certain wear patterns or stiff hips.
@DrDimitrios
Too often students enter med school w/altruism,compassion& happiness. At some point(not sure if it’s in internship,residency or practice),those same people become cynical,emotionally drained&despondent.The feeling that as a doc you should suppress&override emotionally causes harm