Should I routinely order bone scans for ongoing pain after TKA?

[Timeoutofmind]

I understand that this can be ordered to assess for hardware loosening not seeing on plain films.

Makes sense.

Would you order it on any post TKA still in pain patient with a negative infectious workup?

The issue is that the orthopods that refer the failed TKAs to me for geniculars do not order these ever, although they do often do an infection workup. Interestingly, none of them ever order a bone scan, and I see patients from many different orthopods locally.

The point being, if a scan is positive or marginally positive I am no expert at interpreting this in the larger clinical picture of prosthetic loosening. So if I kick a scan like this back to them they might be like WTF is this? And I really dont have the tools in my tool bucket to interpret all of it on my own in terms of clinical significance.

Thanks

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[SSdoc33]

I understand that this can be ordered to assess for hardware loosening not seeing on plain films.

Makes sense.

Would you order it on any post TKA still in pain patient with a negative infectious workup?

The issue is that the orthopods that refer the failed TKAs to me for geniculars do not order these ever, although they do often do an infection workup. Interestingly, none of them ever order a bone scan, and I see patients from many different orthopods locally.

The point being, if a scan is positive or marginally positive I am no expert at interpreting this in the larger clinical picture of prosthetic loosening. So if I kick a scan like this back to them they might be like WTF is this? And I really dont have the tools in my tool bucket to interpret all of it on my own in terms of clinical significance.

Thanks

no. it is the ortho's job to order it. plain x-rays will show most problems after TKAs. bone scan may be more sensitive, but that is not your problem.

 

[Dr. Ice]

Depends on your practice set up, and how patients are scheduled. I work for an ortho group so I routinely order them on patients with ongoing knee pain post tka. My reasoning is often times patients from other groups will come to us with continued knee pain post tka and our guys don't want to necessarily get involved with some other surgeons work so they will be filtered to us by scheduling for "pain management." Being a veteran employee of an ortho group I know this is not unique to our practice. I will order the study interpret it and turf it if needed or try to treat it non surgically. Invariably the conversation goes "well did you go back to the original surgeon?" And invariably the answer is "I tried to but they refused to see me." Must be nice to be ortho....

As an aside there maybe a paradigm shift to spect/ct to evaluate hardware as there are limitations to bone scan..

 

[cowboydoc]

I'm in a similar set-up to Ice, used to have an ortho second opinion before considering blocks/rf on post-TKA pts. I've laxed that, and if there is an ortho that has documented workup negative for complication and there is plain films and reasonable infectious rule out, I'll offer it. I had a patient with a bone scan that said suspicious for infection, turfed to a partner for a 2nd opinion, and he said, "That looks exactly as I'd expect a year out from TKA." I offered blocks, and interestingly she got a 3rd opinion and revision instead?!?

Interested to see where this spect/ct goes...

 

[Dr. Ice]

I'm in a similar set-up to Ice, used to have an ortho second opinion before considering blocks/rf on post-TKA pts. I've laxed that, and if there is an ortho that has documented workup negative for complication and there is plain films and reasonable infectious rule out, I'll offer it. I had a patient with a bone scan that said suspicious for infection, turfed to a partner for a 2nd opinion, and he said, "That looks exactly as I'd expect a year out from TKA." I offered blocks, and interestingly she got a 3rd opinion and revision instead?!?

Interested to see where this spect/ct goes...

In my parts there is a joint surgeon with a large ortho practice who is marketed as the "revision specialist" gimme a freakin break...

 

[cowboydoc]

In my parts there is a joint surgeon with a large ortho practice who is marketed as the "revision specialist" gimme a freakin break...

Wow! Are there that many bad orthos that there is a significant market for that? One of our guys trained at Mayo, so he fixed a lot of messes, but revision certainly isn't his 'calling card.'

 

[Aether2000]

I would order them only after the patient had been evaluated by two independent orthopedists who told the patient they had nothing else to offer.

 

[Disciple]

Wow! Are there that many bad orthos that there is a significant market for that? One of our guys trained at Mayo, so he fixed a lot of messes, but revision certainly isn't his 'calling card.'

It's just really competitive/saturated in some areas. I've met more than a few struggling Sports/arthroscopy guys and even some struggling spine surgeons.

It's not uncommon for large Ortho groups to bring on a fellowship trained total joint guy as a hip/knee revision specialist.

 

[Dr. Ice]

It's just really competitive/saturated in some areas. I've met more than a few struggling Sports/arthroscopy guys and even some struggling spine surgeons.

It's not uncommon for large Ortho groups to bring on a fellowship trained total joint guy as a hip/knee revision specialist.

True still think it's bs though. This group that I used to work at marketed this joint surgeon as revision specialist but the guy wasn't exactly enomored to do them. In fact he used to refer most of the post tka pain patients to us citing "I think the pain is coming from your back.." really bro?!

 

[Timeoutofmind]

I would order them only after the patient had been evaluated by two independent orthopedists who told the patient they had nothing else to offer.

So your protocol for people sent to u for post TKA pain is:
2nd opinion
Then bone scan
Then geniculars if above two negative?

If the bone scan is positive u send back to the original surgeon?

 

[Dr. Ice]

1) Thorough H&P (rule out hip as an associated pain generator...seen a bunch of these)
2) X-ray
3) labs and bone scan (if x ray non revealing)
4) review bone scan with ortho
5) geniculars if they aren't interested in taking over

Obviously this is cause my partners are ortho. If you're getting direct referrals for geniculars from outside ortho and you know that the referring source would have already carried out the due dilligence of above then just do the geniculars and call it a day.

 

[lobelsteve]

Genicular first.
If negative, then bone scan.
Assume xray and esr/crp normal.

 

[emd123]

no. it is the ortho's job to order it. plain x-rays will show most problems after TKAs. bone scan may be more sensitive, but that is not your problem.

Agree. If I'm worried enough about hardware loosing to order a bone scan, I'm instead sending them to ortho to determine and treat, hardware loosening. They can order a bone scan, X-rays or whatever else they need to make that call. And I agree, I haven't seen ortho order many of these. They get the x-ray and either say, "Bone broke" or "bone no broke," kick the patient out the door and drag their knuckles down the hallway.

 

[Timeoutofmind]

Agree. If I'm worried enough about hardware loosing to order a bone scan, I'm instead sending them to ortho to determine and treat, hardware loosening. They can order a bone scan, X-rays or whatever else they need to make that call. And I agree, I haven't seen ortho order many of these. They get the x-ray and either say, "Bone broke" or "bone no broke," kick the patient out the door and drag their knuckles down the hallway.

What kind of things would make u worried about hardware loosening...given if their is an X-ray that looks good say?

 

[clubdeac]

Yeah I'm not seeing many ortho's in my area order bone scans routinely for pain following TKA. They usually just get xrays and if exam c/w normal healing they turf to me. If xrays or exam are concerning then they may order labs or a bone scan but these are certainly not commonplace