Friday, May 15, 2015

How to Improve Total Knee Replacement (TKR) Results

Here are five "fun facts" about Total Knee Replacement.

1.  Have the same surgical team for every case (Surgeon, Assistant Surgeon, Circulating Nurse, Scrub Tech, Second assistant, and anesthesia).  30 day readmission rates due to complications are lower when consistent teams are used.

2.  Use Saphenous Nerve blocks (adductor canal blocks).  This provides better post op pain relief and shorter hospital stays or allows for same day Total Knee surgery.

3.  Emphasize the importance of post op rehabilitation.  Stronger quadriceps muscles are correlated with increased patient satisfaction after TKR.

4.  Unexplained knee pain 6 months after TKR surgery predicts a poor functional outcome at 2 years post op.

5.  Total Joint clinics see a higher percentage of obese people than are present in the total population.  Obesity is a modifiable risk factor for hip and knee osteoarthritis.

Friday, May 8, 2015

Surgical Attire and Infection Prevention

Surgical site infections in the USA are a common and costly complication.  Yearly 300,000 post op infections occur costing 10 billion dollars annually.

The definition of a surgical site infection is an infection apparent after 30 days or when an implant is used the time is one year.  

Here is what we know:

Sterile gloves and impervious surgical gowns reduce surgical site infections.  Orthopedic surgeons routinely double glove when placing implants (two gloves on each hand for added protection) and impervious gowns are the routine.

Scrubs, masks, and head coverings reduce bacterial counts in the Operating Room.

Fluids and surgical instruments are exposed to air borne bacteria in the operating room.

People are the major source for bacteria in the operating room, so it makes sense that limiting human room traffic is good policy.

Friday, May 1, 2015

Perfection After Total Knee Replacement - Is This Possible ?

Total knee replacement has been around for over 40 years.  
There have been advances in the
understanding of disease processes.  There have been improvements in implant design.  Surgical precision is close to perfection.  Patient selection and perioperative management is quite sophisticated. 

So the question has been raised as to whether implant failures and other complications such as blood clots and periprothetic infections should be classified as "never events" .  

The short answer is no, these problems are unavoidable.  Numerous factors related to the surgeon, the implant, and the patient will always preclude 100 % success rates.  Human variables continue to exist which means so does the small but finite risk of total knee replacement surgery failure. 

It remains unrealistic for insurers, policy makers, consumer advocates and patients to expect absolute perfection with this complex surgery.

Friday, April 24, 2015

Are Patients More Fit After Total Knee Replacement Surgery ?

Contrary to popular conception, patients generally do not experience a reduction of body mass after surgery.  A study reported by Yong Qiang Jerry Chen, MBBS analyzed 7,733 patients after total knee replacement surgery.  

After surgery 14 % had a reduction in BMI, 65 % maintained their BMI, and 21 % had a gain in BMI.     Most patients either stayed the same or gained weight.  

This studies shows the importance of optimizing BMI prior to total knee replacement surgery since 86 % of patients will not lose the weight by eating better and exercising more after surgery.  

Long term health and good outcomes after knee replacment surgery is improved in patients that have optimal BMI, have healthy eating behaviors, and exercise on a regular basis.

Friday, April 17, 2015

It Is Safe to Go Home After Total Knee Replacement

Two studies presented this week at the AAOS Annual Meeting support discharge to home after knee replacement.  One study showed that knee function (walking, bending) was not improved by inpatient rehab and the other showed that healthy patients that went home did not suffer serious complications.

One study by Douglas Padgett, MD looked at nearly 8,000 Total Knee patients and found that rehabilitation and prescribed exercises can be done just as well at home/outpatient physical therapy.  There is no evidence to support the routine use of inpatient rehab facilities or extended care facilities.  The stiffness rate (need for manipulation under anesthesia) was 4 % for each group.

Another study showed that early discharge to home did not increase the 30 day readmission rate.  This is further information to support that bad things do not happen to Total Joint replacement patients that were discharged to home as same day patients.  Same Day Total Knee Replacment appears to be a safe alternative to inpatient hospitalization for the same procedure.