Orthopaedic Progress Note

Progress Note

14/05/2024

Subjective

• F/U for R knee OA and L trochanteric bursitis.
• R knee pain progressive over 2 yrs, now 8/10 severity. Aggravated by weight-bearing and stairs, minimal relief with rest. Failed conservative mgmt including IA corticosteroid injections and celecoxib (Celebrex®) 200 mg PO daily. L lateral hip pain present for 3 mos, 4/10, worse lying on L side.
• Undertaking PT for R knee; progress is unsatisfactory due to pain-limited ROM.
• R knee symptoms significantly worsened since last visit 6 mos ago; walking distance reduced to < 1 block. Overall functional decline.

Objective

• R knee: Varus alignment. Moderate effusion. Medial joint line tenderness. ROM 10° to 95° flexion (extensor lag 10°). Crepitus throughout arc. Stable to varus/valgus stress. L hip: Tenderness over greater trochanter. Full ROM, pain with resisted abduction.
• Distal neurovascular exam intact B/L: DP/PT pulses 2+, sensation intact to light touch in L4-S1 dermatomes, EHL/FHL/gastroc-soleus power 5/5.
• XR R knee (weight-bearing, 10/05/2024): Severe tricompartmental OA, bone-on-bone medial compartment, osteophytes, subchondral sclerosis. Pre-op labs: Hb 138 g/L, WBC 6.5 x 10^9/L, Plt 240 x 10^9/L, Cr 78 µmol/L, INR 1.0.

Assessment & Plan

1. End-Stage Right Knee Osteoarthritis

• Severe R knee OA refractory to non-operative management, supported by clinical exam and radiographic bone-on-bone changes.
• Pre-op ECG and CXR ordered for anaesthetic clearance.
• Booked for R Total Knee Arthroplasty (TKA), cemented, posterior-stabilised prosthesis.
• Continue paracetamol (acetaminophen, Tylenol®) 1,000 mg PO QID PRN and celecoxib (Celebrex®) 200 mg PO daily until 5 days pre-op.
• Referral to pre-admission clinic and post-op inpatient/outpatient PT.

2. Left Greater Trochanteric Pain Syndrome

• Clinical findings consistent with L trochanteric bursitis, likely secondary to altered gait mechanics from R knee pathology.
• Trial of targeted PT for gluteal strengthening and IT band stretching; continue current oral analgesia.
• Outpatient PT referral updated to include L hip protocol.

Additional Notes

• Educated pt on TKA procedure, expected hospital stay (1-2 days), importance of early mobilisation, and strict adherence to post-op rehab protocol.
• Pt expressed concern regarding post-op pain management and living alone; discussed multimodal analgesia and arranged SW consult for home care support.
• Informed consent completed for R TKA; discussed diagnosis, surgical procedure, non-surgical alternatives, and material risks.
• Material procedural risks discussed, including infection, bleeding, transfusion requirement, nerve or vessel injury, ongoing pain or stiffness, fracture, implant loosening or wear, reoperation, tourniquet pain, venous thromboembolism, medical or anaesthetic complications, and death.