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Orthopedic Surgery

Medication Management

Summary

  • 58-year-old incarcerated male with chronic right knee pain
  • Given the difficulty of obtaining an orthopedic consult in patient’s setting, PCP submitted an eConsult to seek guidance for next steps in management
  • Specialist provided both medication and non-medication recommendations

eConsult Transcript

PCP submission

58 y/o incarcerated offender with right knee pain who is requesting MRI. Offender was hit by car in 2009 with multiple fractures and surgeries. Right leg with intermedullary nail and fixation of tibia plateau fractures. He has had chronic issues and wears a knee brace. However slipped and injured rt knee 12/2021. Now feels internal pain and lateral osterior knee pain.

Exam: swelling to knee 2 mos ago now resolved but deep crepitus noted with extension flexion of knee. Only able to partial squat while supported and difficulty standing. ligaments intact/no laxity.

Attachment xray results from 1/28/22

It is difficult to obtain an orthopedic consult from our setting. What are the best next steps in management?

Specialist response

Hi, thank you for your question! Based upon the image and x-ray reports provided, the patient appears to have significant hardware placed to the distal femur  and proximal tibia. Fortunately, on repeat films there appeared to be no change in the alignment or the previous hardware. It was noted that the patient does have worsening knee osteoarthritis to the knee, which would be consistent with the patient’s knee pain and crepitus. Based upon this, I would treat his knee for osteoarthritis. There are 3 options in treating osteoarthritis. 1) Physical therapy, focusing on quadricep strengthening, and oral NSAIDs to reduce inflammation. 2) Intra-articular injections, which come in two types: cortisone or hyaluronic acid (ie. synvisc). 3) Surgery – the final option is a total knee arthroplasty. I would start with NSAIDs and therapy. If he fails to improve, then I would consider cortisone and then gel injections. The last and final option would be a total knee replacement. A MRI could also be done at some point, but it may not be that helpful since the previous hardware will distort the images. I hope this helps guide your treatment. Thank you for your consult!

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