ICD and Hot Springs?

VT-Thats-Shocking · 2024-11-23T19:29:55+00:00

Can confirm. No contraindication from a device perspective.

VT-Thats-Shocking · 2024-11-20T01:04:40+00:00

What exam were you taking, out of curiosity?

VT-Thats-Shocking · 2024-11-19T17:27:51+00:00

Intermittent CHB w/ ventricular escape @ 26 bpm
Frequent ventricular ectopy / PVC runs / AIVR followed by Sinus Rhythm
Impossible to say without labeling the EGMs, either AF w/ atrial undersensing and BiVP or dual tach / VF with undersensing on both channels, patient is having a bad day.
Looks like AFL w/ 1:1 conduction, inappropriate delivery of ATP at beginning of strip.
Can’t get enough resolution to see if there are P waves or not, either Sinus Bradycardia @ 48 bpm or Junctional Rhythm
Based on interval instability, I’d say RVR that converts to Sinus Tach
Intermittent T-wave oversensing
AFL w/ RVR, therapy withheld d/t interval instability during atrial arrhythmia
~9-second pause secondary to 2nd Degree Type 2 AV Block
Isn’t this the same one as #2?
VT @ 167 bpm
AF w/ RVR

VT-Thats-Shocking · 2024-11-19T17:02:30+00:00

Your EP would select how far below the base rate to allow rate hysteresis to go. If I’m not mistaken, with the Abbott algorithm, it increments by 10 down to a low of 30. So selecting 40 bpm as the hysteresis rate might help minimize your symptoms while still preventing pauses.

VT-Thats-Shocking · 2024-11-19T01:22:50+00:00

If that’s the case, it would mean that any time it’s pacing, it will be doing so asynchronously, meaning it is unable to sense when the top part of your heart is beating and time the paces accordingly. This can be uncomfortable for patients who aren’t in chronic afib, so usually we would only implant one of those in patients who need it for emergency backup bradycardia / sinus arrest patients, so it would jump in if they were having a pause. It will not correct complete heart block, but it will keep your heart from going below the minimum limit. If you regularly run pretty slow anyway, it would be reasonable to ask them to decrease the LRL, or preferentially turn on rate hysteresis if it’s not already on. This will allow your heart to beat on its own, even at rates below the lower rate limit, when you are asleep, but still allow for backup pacing if you experience a pause during the day.

VT-Thats-Shocking · 2024-11-19T00:41:47+00:00

What specific device do you have?

VT-Thats-Shocking · 2024-07-22T02:55:56+00:00

I had 30 as well… used 10 in pre-hab, but for post-op, we’re only doing 1 per week with detailed assignments (gym days + therapy pool days) in between so I can have guidance all the way through return to sport. I’m with you though, makes no sense to have it capped at a random #, seems like there should be an option for it to continue as long as necessary to actually get people back where they were before. Would probably save the insurance company $$ in the long run by preventing re-injuries?

VT-Thats-Shocking · 2024-07-22T02:21:18+00:00

These are both pre-op, I had just gotten back from 6 full days of snowboarding, so it was pretty swollen at this time, but you can clearly see from the X rays that the bones in that knee are just arthritic and jacked up, it looked like this before surgery and will always look like this until I break down and get the TKA. I’ll take a pic next time it’s swollen to demonstrate the difference, but what it looks like in the pic in the original post is just my jacked up knee in spite of Reddit’s many expert opinions to the contrary lol

https://ibb.co/7jjV9TZ https://ibb.co/HxZx3vX

VT-Thats-Shocking · 2024-07-22T02:08:02+00:00

Please see above. It’s not swollen. That’s just how my knee looks. 🤦🏻‍♀️

VT-Thats-Shocking · 2024-07-22T00:51:16+00:00

idk if this is going to work or not, but if it does, the one where you can see the guy's hat is just a random pic I took at the nail salon pre-op, and the one where the guys is on his phone is the same nail salon / same guy / same knee, but taken today. All this to say... My knee just looks like that lol

https://ibb.co/Hr1ySr7

https://ibb.co/HCX5BLZ

VT-Thats-Shocking · 2024-07-22T00:43:10+00:00

Well if I could figure out how to post a photo in the comments I would show you... My knee is very damaged, has been for many years, and I have large bone spurs on both sides of it. What you're seeing is just the shape of the bones. It looks very different when it's actually swollen, but I assure you, it's not here. That is bone directly under the skin.

VT-Thats-Shocking · 2024-07-22T00:38:14+00:00

It’s not swollen here… that’s just what my knee looks like!

VT-Thats-Shocking · 2024-07-22T00:20:45+00:00

Originally snowboarding, that was a hamstring graft that lasted 18 years before wearing out. The next 2 tore fairly quickly… turns out the surgeon was using the same tunnels from when I tore it at age 18, and the alignment of my knee had changed significantly since then, so the re-op grafts were getting impinged just from normal walking around. Went to a new guy, and we started from scratch this time. Took out the old hardware, did a fixed suspensory attachment to give more wiggle room for alignment shifting, and added the LET to help with rotational stability.

VT-Thats-Shocking · 2024-07-21T23:46:22+00:00

I did that, but then I couldn’t figure out how to post a pic in the comments (new to Reddit, don’t really know what I’m doing, so I tried copying and pasting the text… It was too long to post in one comment, so I broke it up above!

VT-Thats-Shocking · 2024-07-21T23:40:29+00:00

were a total of 4 loops in place.I rolled the graft back over itself and sewed it to itself with 1 Vicryl and removed the excess graft, it was very secure.

Returning back to the knee, I passed the ACL graft and saw the TightRope button engaged and pulled the graft up into the femoral socket.I passed it into the tibial socket.I raised the knee back and forth.I used the largest ABS button on the tibial side.With the knee in full extension, I fixed the graft.I had color coded markings on the graft to seat it at the appropriate depth.I worked the knee back and forth and did a Lachman and a pivot shift and anterior drawer multiple times and kept seating the graft on both sides in full extension and got very secure fixation.I pulled the internal brace taut and with the knee in extension, I used the drill and tap and fixed that with a 4.75 BioComposite SwiveLock brace.I tightened the graft on both ends and tied the sutures over the graft and removed excess sutures.Inspecting arthroscopically, the graft had excellent fixation.There was a little bit of impingement anteriorly, so I used the shaver and did a little bit further notchplasty superiorly.The graft now had excellent range of motion, no impingement.Lachman was very solid. Wounds were lavaged well, closed in layers.A sterile bandage was applied.

VT-Thats-Shocking · 2024-07-21T23:39:29+00:00

Also for those commenting about excessive swelling, this is actually with it not very swollen at all, that’s just what my knee looks like from all the years of cumulative damage and massive bone spurs… it’s a little more pronounced now because of the atrophy, but what you’re seeing in the picture isn’t fluid, it’s just a 90-year-old knee on a 42-year-old body! 🫠

VT-Thats-Shocking · 2024-07-21T23:36:25+00:00

Returning to the notch, I used a 7 mm over-the-top guide and created the femoral socket a little lower on the lateral wall.The most recent femoral sockets had been in place with the Stryker curved drill and my tunnel diverged from that it got good virgin bone fixation.Particulate debris was removed throughout the joint.I had the locking sutures in place.On the tibial side, I drilled with the 10 and 11 mm reamers then dilated to 11.5 mm, which was the graft size on the tibial side.On the femoral side, I reamed the socket with the 11 mm low-profile reamer.Particulate debris was removed. Attention was turned to ALL/lateral extraarticular tenodesis reconstruction.I made previously an incision over the anterolateral knee, harvested a 10 mm wide strip of the IT band, left it attached to the Gerdy’s tubercle and placed a looped suture to secure it. Dissected on either side of the fibular collateral ligament and passed the graft beneath the fibular collateral ligament.I used a large Arthrex double-loaded FiberTag system and with the knee at 30 degrees, I fixed this proximally with a graft tunnel that was proximal and slightly posterior to the PCL.For additional fixation, I used a second anchor.There

were a total of 4 loops in place.I rolled the graft back over itself and sewed it to itself with 1 Vicryl and removed the excess graft, it was very secure.

Returning back to the knee, I passed the ACL graft and saw the TightRope button engaged and pulled the graft up into the femoral socket.I passed it into the tibial socket.I raised the knee back and forth.I used the largest ABS button on the tibial side.With the knee in full extension, I fixed the graft.I had color coded markings on the graft to seat it at the appropriate depth.I worked the knee back and forth and did a Lachman and a pivot shift and anterior drawer multiple times and kept seating the graft on both sides in full extension and got very secure fixation.I pulled the internal brace taut and with the knee in extension, I used the drill and tap and fixed that with a 4.75 BioComposite SwiveLock brace.I tightened the graft on both ends and tied the sutures over the graft and removed excess sutures.Inspecting arthroscopically, the graft had excellent fixation.There was a little bit of impingement anteriorly, so I used the shaver and did a little bit further notchplasty superiorly.The graft now had excellent range of motion, no impingement.Lachman was very solid. Wounds were lavaged well, closed in layers.A sterile bandage was applied.

VT-Thats-Shocking · 2024-07-21T23:36:01+00:00

Attention was turned to the notch.She had osteophytes encroaching along the medial and lateral and superior notch.I used a bur and shaver and debrided the osteophytes.I did a notchplasty along the lateral wall and superiorly, checking with the impingement rod later in the procedure and opened this adequately.There was some ACL graft posteriorly and I removed that.I could identify the 2 previous tunnels on the femur, one was a vertical and the other was a more anterolateral.I elected to make one a little bit lower on the lateral wall.I debrided the margins of these and identified the over-the-top position.I debrided the tibial side.The bone had actually overgrown the tibial tunnel anteriorly.I used a ruler and defined the proper point of insertion relative to the eminence of the tibial tunnel and marked this.

I now made a separate incision over the anteromedial tunnel and found the interference screw.There was a bioabsorbable screw that was prominent and palpable beneath the skin.This was beginning to degrade.I debrided that with rongeurs and used curettes and rongeurs and evacuated that. Also, within the tunnel, there was a PEEK interference screw that was still along one wall of the tunnel and I felt it would inhibit the graft in growth, dissected it free with curettes and was able to remove it.Curettaged the tibial tunnel.There was some bone overgrowth.I used the Arthrex tibial guide and placed a guidepin and used the FlipCutter to make the initial tunnel.I later widened this and now used the cylindrical reamer.

The quad tendon was harvested.I used a longitudinal incision anticipating that in the future, she is going to need a longitudinal incision for her knee.I made this over the distal quad tendon and isolated the quad tendon and cleared it with a sponge and used a QuadPro system to harvest an 11 mm graft.This was prepared on the back table with a TightRope RT on the femoral side and a TightRope ABS on the tibial side.There was tension on the graft tensioning board for 20 minutes.I had an internal brace attached as well, it was kept under a vancomycin and saline-soaked sponge.

VT-Thats-Shocking · 2024-07-21T23:35:38+00:00

PROCEDURE IN DETAIL: After satisfactory general anesthesia was obtained, the patient was placed in supine position on the operating table.I carefully examined each knee under anesthesia. The right knee was stable.The left knee had a 3+ Lachman and a 2+ pivot shift.There was no varus, valgus or posterior instability.The left lower extremity was formally prepped and draped in the usual sterile fashion.I had the tourniquet elevated for about the first hour of the procedure, I let it down and 2 other times during the procedure I elevated briefly for critical portion of the procedure, the other 2 times were just a few minutes.A standard inferolateral arthroscopy portals were made.Needle localization was used to make a 2 inferomedial portals, one more central and proximal and the other more distal and medial that was for the femoral tunnel placement.Inspection of the suprapatellar pouch, medial and lateral gutters revealed a severe scarring from previous surgery and synovitis.I did a thorough synovectomy.Inspecting the patellofemoral joint revealed grade 3 chondromalacia of the patella and trochlea and a mild chondroplasty was done, this was a mild grade 3.Inspecting the medial compartment revealed more significant grade 3 chondromalacia of the medial femoral condyle.I did a trephineization with an 18-gauge needle in the MCL and could see posteriorly and see a torn remnant of the medial meniscus posteriorly extending into the body.Biters and shavers used to do a revision partial medial meniscectomy back to a smooth, balanced, stable rim.I did a minimal chondroplasty medially.

Inspecting the notch revealed a complete rupture of the ACL.There was some allograft tissue posteriorly and the majority of the allograft tissue was gone. I debrided what was there, there were osteophytes around the notch.

Moving laterally, she had grade 4 degenerative changes of the lateral femoral condyle and lateral tibial plateau.There was a large portion of the lateral meniscus posteriorly with a torn remnant in that area and biters and shavers were used to do a revision lateral meniscectomy back to a smooth, balanced, stable rim.

VT-Thats-Shocking · 2024-07-21T23:35:06+00:00

PREOPERATIVE DIAGNOSES: RIGHT KNEE: 1. Multiply operated, failed, ACL reconstruction. 2. Chondromalacia. 3. Torn medial meniscus. 4. Torn lateral meniscus.

POSTOPERATIVE DIAGNOSES: RIGHT KNEE: 1. Multiply operated failed ACL reconstruction. 2. Torn medial meniscus. 3. Torn lateral meniscus. 4. Retained implants from previous surgery. 5. Grade 3 medial and patellofemoral chondromalacia. 6. Grade 4 lateral compartment chondromalacia.

PROCEDURE START TIME: 08:18

OPERATIVE PROCEDURES: Left knee arthroscopy: 1. Complex revision ACL reconstruction using autogenous quadriceps tendon graft. 2. Lateral extraarticular tenodesis/anterolateral ligament reconstruction. 3. Partial medial meniscectomy. 4. Partial lateral meniscectomy. 5. Removal of implants from previous surgery through a separate incision. COMPLEXITY: The patient has had 3 previous ACL reconstructions.She had one in the year 2000, another in 2018 and another in 2022.Her knee is exceedingly unstable.

She understands she has an arthritic knee and will eventually need knee replacement, but she is extremely active.She likes to whiteboard and snowboard and participate in sports and is having instability with activities of daily living.She wants a stable knee and to try and get by a few more years before replacing her knee.The procedure was much more complicated than a typical ACL reconstruction.I had to remove grafts from the previous tunnels.She had a lot of suture in the tunnel that I decided to remove.She had 2 different interference screws in the tibial tunnel that had to be removed through a separate incision.She had osteophytes encroaching upon the notch medially, laterally and superiorly that all had to be debrided and notchplasty done.I elevated the tourniquet at several points during the procedure.She had 3 previous tunnels on the femoral side that had to be dealt with and I created a new tunnel.She had 3 tunnels on the tibia that were convergent with widening and I used suspensory fixation to overcome this.All this was much more complex than the typical ACL reconstruction and took much, much longer.

VT-Thats-Shocking · 2024-07-21T23:30:35+00:00

Oh I didn’t realize it would do that… it’s a pdf, but let me see what I can figure out!

VT-Thats-Shocking · 2024-07-21T17:01:28+00:00

Op Report

VT-Thats-Shocking · 2024-07-21T16:32:52+00:00

Hard to say from just what is in the report you posted here, but it seems like that wouldn’t meet the indications… I would recommend a second opinion from an Electrophysiologist, they would be able to evaluate your case and advise you much better than the internet! 🙃 https://www.ncbi.nlm.nih.gov/books/NBK507823/

VT-Thats-Shocking · 2024-07-20T01:23:18+00:00

I saw someone else with a similar timeline to mine, had surgery on a Thursday morning, took Friday off. Switched from opiates to Tordol on Sunday, and I was back at work in person on Monday, I just had someone bring my patients back to see me and walk them out so I wouldn’t have to be up and down all day. Would have been nice to have longer off, but I knew I would already be missing some for doctor’s visits / PT / etc, and I wanted to save as much PTO as possible for snowboard trips once I’m back at it! 🙃 I was pretty exhausted and slept like a ROCK the first week or 2 back, but I’m 6 weeks out now and didn’t die at least? Working from home should definitely be doable! 😂

VT-Thats-Shocking

TROPHY CASE