Disclosures Hip and Knee Replacements Paid teaching at the Depuy - PowerPoint PPT Presentation

Disclosures Hip and Knee Replacements  Paid teaching at the Depuy Fellows Course What’s New in 2018 and What the PCP Needs to Know Derek Ward, M.D. Assistant Professor of Orthopaedic Surgery Division of Adult Reconstruction University of California, San Francisco 12/13/2018 2 Outline First of all…  Burden of Disease and Epidemiology  The Basics of Hip and Knee Replacement  THANK YOU!  What’s changed over the last decade Longevity - Pain Management - Hospital Stay - Thromboembolism prophylaxis - Risk Reduction - 3 4 1

Please Meet Rose Question What is the most common inpatient surgery performed in the US? 49% Percutaneous coronary angioplasty A. 38% Total hip replacement B. Lumbar Laminectomy C. Appendectomy D. Total Knee Replacement E. 7% 5% 1% Prese ntatio 5 Presentation Title n Title 6 Burden of Disease  Arthritis is the most common cause of disability in the US  22.7% of adults have doctor-diagnosed arthritis 43.2% of patients with arthritis report activity limitations due to - disease  Cost estimates (2003) = $128 Billion, 1.2% of GDP 7 Presentation Title 8 2

Utilization Causes of Increased Utilization  Aging Population  By 2030:  Patients receiving arthroplasty 3.5 million TKA (673%) - at a younger age 570,000 THA (174%) - Improvements in technology - Obesity - 9 10 Arthritis Diagnosis  Cartilage Degeneration  Symptoms but….largely radiographic Pain - Limp -  Radiographs – Weight bearing! Swelling - Knee: AP, Rosenberg, Lateral, Patellofemoral Views - Loss of range of motion - Hip: Low AP Pelvis, Frog-leg lateral - Eventual deformity -  MRI is rarely necessary  Causes Expensive - Osteoarthritis- “wear and tear” - Brings in other issues - Inflammatory arthritis - Unnecessary treatment - Trauma, old fractures - Osteonecrosis- “lack of oxygen to the bone” - Childhood/ developmental disease - 11 12 Presentation Title 3

Knee Arthritis Hip Arthritis  X-ray  Clinical  X-ray  Clinical 13 Presentation Title 14 Presentation Title Inflammatory Arthritis Trauma  Autoimmune  Higher risk population  New perioperative medication recommendations 15 16 Presentation Title 4

Osteonecrosis Childhood Hip Disease  Steroids  Developmental Dysplasia  HIV/HAART Spectrum of Disease -  Alcohol 17 Presentation Title 18 Presentation Title What Surgeries Do We Perform? What is Arthroplasty  Knee arthroplasty Unicompartmental  “Arthro”- joint; “plasty”- - reconstruction Primary/ Revision -  Replacement of the  Hip arthroplasty diseased joint surface w/ Primary/ Revision - a prosthesis (metal, plastic, ceramic)  Hip arthroscopy – Usually Sports medicine  Knee arthroscopy - Usually sports medicine 19 Presentation Title 20 Presentation Title 5

High-Impact Intervention 21 22 Presentation Title Total Hip Arthroplasty (THA) THA  Components Acetabular component/ socket/ - shell/ cup- Titanium Acetabular liner- PE vs CoCr vs - ceramic Femoral head- CoCr vs ceramic - Femoral component/ stem- - Titanium  Fixation: cementless >> cemented, hybrid - 23 Presentation Title 24 Presentation Title Zimmer.com 6

Total Knee Arthroplasty (TKA) TKA  3 compartments: medial/ lateral/ patellofemoral -  Components: Femoral component- CoCr - Tibial component-Titanium/CoCr - Tibial liner/ tray/ insert- PE - Patellar component/ button- PE -  Fixation: Cemented >> cementless - 25 Presentation Title 26 Presentation Title Unicompartmental Knee Arthroplasty (UKA) Revision TKA  Infection  Loosening  Fracture  Instability 27 Presentation Title 28 Presentation Title 7

Question Revision THA You have a 45 year old otherwise healthy patient with moderate knee arthritis who has failed oral NSAIDS and Tylenol, physical therapy, bracing, and injections. What do you tell them?  Infection  Loosening 90% “Hang in there as long as you can and deal with the A.  Fracture pain until you are 65”  Dislocation “I would like to refer you to a surgeon to discuss your B. options” “Let start you on a little bit of Percocet” C. ”I know a great stem cell guy….he’s relatively cheap” D. 5% 5% 1% Prese ntatio 29 Presentation Title n Title 30 Changes in Arthroplasty Changes in Arthroplasty - Safety  Too Old for Arthroplasty?  Longevity Quality of life decision - Too young for arthroplasty? - No difference in 1-year mortality -  50s? when age-adjusted for expected  40s? mortality rates  30?s…. Frailty and medical co- - Quality of life decision/balance - morbidities play a larger role  Approximately 1% failure rate than age per year for any reason  Change in expectations  Changes in implant technology https://www.waterskimag.com/features/2015/04/08/joint-replacement-doesnt-have-to-end-your-skiing-life#page-2 31 32 8

Question Changes in Arthroplasty – Pain Management What is the appropriate chemical DVT prophylaxis for a 68 year old otherwise healthy female undergoing joint replacement?  Multi-modal, non-opiate based regimen Spinal anesthesia - Coumadin with a goal INR of 2-3 x 6 weeks A. Regional nerve blocks/catheters - 29% 29% Apixaban 5mg Daily B. Acetaminophen, celecoxib, gabapentin ATC - 21%  Most patients are off narcotics in a matter of weeks Enoxaparin 30mg BID C. 18% THA patients, 1-2 weeks - Aspirin 81mg BID D. TKA patients 4-6 weeks - No chemical prophylaxis needed E.  Change in expectations….. 3%  Surgeons are well aware of the role we play in the opioid crisis Prese ntatio 33 Presentation Title n Title 34 Question Changes in Arthroplasty – DVT prophylaxis What is the appropriate antibiotic prophylaxis for a 68 year old  Most patients are on Aspirin 81mg PO BID x 4 weeks otherwise healthy female undergoing a routine cleaning 3 months postoperatively? No increased risk in DVT/PE - 78% Decreased wound complications, infection, bleeding events - Keflex 500mg PO q6 x 1 week A. No need for injections/monitoring - Doxycycline 100mg PO BID x 4 days Lower risk of needing a blood transfusion - B.  All patients Amoxicillin 500mg PO BID x 2 doses C. Neuraxial anesthesia - No antibiotic prophylaxis needed D. 20% Rapid mobilization - Z-pac E. SCDs - 1% 1% 1%  Risk stratification Enoxaparin, Warfarin, Xa Inhibitors - Xa inhibitors =? Infection risk - Prese ntatio 35 Presentation Title n Title 36 9

Dental Prophylaxis Changes in Arthroplasty – Hospital Stay and Rapid Recovery “Doc, do I need antibiotics before I get my teeth cleaned”  Bottom line….we don’t know if this makes any different  Outpatient procedures for some patients  ADA recommendations, 2015  Average one night in the hospital if inpatient  MOST patients go home (>90%)  ERAS = “Enhanced Recovery After Surgery” Protocols throughout the episode of care -  There is a large move towards outpatient surgery, including in the Medicare population Removal of TKA from inpatient only list in 2018 - 37 Presentation Title 38 Our Protocol Changes in Arthroplasty – Risk Reduction Outpatient Outpatient • Candidate for TKA/THA, meets with Nurse  Diabetes assessment assessment Navigator HgBA1c < 8 - Preoperative Preoperative • Online/App patient class class engagement tool  Smoking Preoperative Preoperative No nicotine - • Email/EMR anesthesia anesthesia communication with Assessment Assessment surgeon/team  Obesity • Protocol Pain Control, BMI < 40 Surgery Surgery - Risk stratified DVT prophylaxis  Chronic Pain Day of Surgery Day of Surgery Assessment by Assessment by Opiates – decrease dose by 50% - PT/OT PT/OT  Substance abuse Discharge Discharge • Most patients have Home Home POD#0 Home POD#0 Health PT, then or 1 or 1 Outpatient PT Minimum documented sobriety period - • Continuous check-in 4-6 Week FU 4-6 Week FU with app/online engagement platform 39 Presentation Title 40 Presentation Title 10

Other Questions/Myths When Bad Things Happen…  Platelet Rich Plasma and  Low Complication Stem Cells for arthritis rate….but....  Certain complications are  Rejection and Metal Allergies devastating and easier to fix if diagnosed early.  Gender Specific Implants  Don’t hesitate to refer any patient with new mechanical symptoms or pain after a hip  Minimally Invasive Surgery or knee replacement  Navigation/Robotics/Computer Assisted http://www.smartchoicestemcell.com/about- 41 42 us/cost-and-financing.aspx Periprosthetic Infection Conclusions  This is absolutely devastating (extremely high morbidity and  Hip and Knee Arthroplasty are rapidly expanding procedures mortality) with excellent long term outcomes  Better if caught early, Almost always requires surgeries (often  Recovery is becoming significantly easier multiple surgeries)  Help us modify the risk factors that we can before surgery  May also require prolonged and even lifelong antibiotics  Rapid referral for patients with painful joint replacements  We have dramatically reduced the incidence of every complication in the last decade….except this one Obesity - Difficulty of eradication - 43 Presentation Title 44 Presentation Title 11

Thank you! 45 12