Hip and Knee Replacements What the PCP Needs to Know Derek Ward, - PDF document

Hip and Knee Replacements What the PCP Needs to Know Derek Ward, M.D. Assistant Professor of Orthopaedic Surgery Division of Adult Reconstruction University of California, San Francisco 12/2/2017 Disclosures  I have no disclosures 2 1 | [footer text here]

Outline  The Basics of Hip and Knee Replacement  What’s changed over the last decade - Longevity - Pain Management - Hospital Stay/Rapid Recovery - Thromboembolism prophylaxis - Risk Reduction 3 Utilization  By 2030: - 3.5 million TKA (673%) - 570,000 THA (174%) 4 2 | [footer text here]

Causes of Increased Utilization  Aging Population  Patients receiving arthroplasty at a younger age - Improvements in technology - Obesity 5 Arthritis  Cartilage Degeneration - Pain - Limp - Swelling - Loss of range of motion - Eventual deformity  Causes - Osteoarthritis- “wear and tear” - Inflammatory arthritis - Trauma, old fractures - Osteonecrosis- “lack of oxygen to the bone” - Childhood/ developmental disease 6 3 | [footer text here]

Diagnosis  Symptoms but….largely radiographic  Radiographs – Weight bearing! - Knee: AP, Rosenberg, Lateral, Patellofemoral Views - Hip: Low AP Pelvis, Frog-leg lateral  MRI is rarely necessary - Expensive 7 Presentation Title Inflammatory Arthritis  Higher risk population  New perioperative medication recommendations 8 4 | [footer text here]

Trauma 9 Presentation Title Osteonecrosis  Steroids  HIV/HAART  Alcohol 10 Presentation Title 5 | [footer text here]

Childhood Hip Disease  Developmental Dysplasia - Spectrum of Disease 11 Presentation Title What Surgeries Do We Perform?  Knee arthroplasty - Unicompartmental - Primary/ Revision  Hip arthroplasty - Primary/ Revision  Hip arthroscopy – Usually Sports medicine  Knee arthroscopy - Usually sports medicine 12 Presentation Title 6 | [footer text here]

What is Arthroplasty  “Arthro”- joint; “plasty”- reconstruction  Replacement of the diseased joint surface w/ a prosthesis (metal, plastic, ceramic) 13 Presentation Title Total Hip Arthroplasty (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 14 Presentation Title Zimmer.com 7 | [footer text here]

Total Knee Arthroplasty (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 15 Presentation Title Changes in Arthroplasty  Longevity - Dramatic decrease in the implant “wearing out” with newer technology - Too young for arthroplasty?  50s?  40s?  30?s…. - Quality of life decision/balance of risk tolerance 16 8 | [footer text here]

Changes in Arthroplasty - Safety  Too Old for Arthroplasty? - Quality of life decision - No difference in 1-year mortality when age-adjusted for expected mortality rates - Frailty and medical co-morbidities play a larger role than age 17 Changes in Arthroplasty – Pain Management  Multi-modal, non-opiate based regimen - Spinal anesthesia - Regional nerve blocks/catheters - Intra-articular injection - Acetaminophen, celecoxib, gabapentin ATC  Most patients are off narcotics in a matter of weeks - THA patients, 1-2 weeks - TKA patients, 4-6 weeks  Change in expectations….. 18 Presentation Title 9 | [footer text here]

Changes in Arthroplasty – DVT prophylaxis  Most patients are on Aspirin 81mg PO BID x 4 weeks - No increased risk in DVT/PE - Decreased wound complications, infection, bleeding events - No need for injections/monitoring - Lower risk of needing a blood transfusion  All patients - Neuraxial anesthesia - Rapid mobilization - SCDs  Risk stratification - Enoxaparin, Warfarin, Xa Inhibitors 19 Presentation Title Changes in Arthroplasty – Hospital Stay and Rapid Recovery  Outpatient procedures for some patients  Average one night in the hospital if inpatient  Very few patients require blood transfusions  MOST patients go home (>90%)  Less need for formal physical therapy  ERAS = “Enhanced Recovery After Surgery” 20 10 | [footer text here]

Changes in Arthroplasty – Risk Reduction  Diabetes - HgBA1c < 8  Smoking/Tobacco - No Nicotine  Obesity - BMI < 40  Chronic Pain - Opiates – decrease dose by 50%  Substance abuse - Minimum documented sobriety period 21 Presentation Title When Bad Things Happen…  Low Complication Rate….but....  Certain complications are devastating and easier to fix if diagnosed early - Infection - Loosening  Don’t hesitate to refer any patient with new mechanical symptoms or pain after a hip or knee replacement 22 Presentation Title 11 | [footer text here]

Key Points  Large expected increase in the need for hip and knee replacement over the coming decades - High impact, cost-effective procedures  Quality of life, frailty, and co-morbidities are more important than age in determining candidacy for surgery  Advances have allowed for less painful surgeries with faster recoveries and low complication rates  Address modifiable risk factors  Refer arthroplasty patients with new symptoms early to catch complications 23 Presentation Title References Mont MA1, Jacobs JJ. AAOS clinical practice guideline: preventing venous thromboembolic disease in patients undergoing  elective hip and knee arthroplasty. J Am Acad Orthop Surg. 2011 Dec;19(12):777-8. Springer BD1. Modifying Risk Factors for Total Joint Arthroplasty: Strategies That Work Nicotine. J Arthroplasty. 2016  Aug;31(8):1628-30. doi: 10.1016/j.arth.2016.01.071. Epub 2016 Mar 26. Harris AH1, Bowe TR, Gupta S, Ellerbe LS, Giori NJ. Hemoglobin A1C as a marker for surgical risk in diabetic patients  undergoing total joint arthroplasty. J Arthroplasty. 2013 Sep;28(8 Suppl):25-9. doi: 10.1016/j.arth.2013.03.033. Epub 2013 Jul 30. Iorio R1, Williams KM, Marcantonio AJ, Specht LM, Tilzey JF, Healy WL. Diabetes mellitus, hemoglobin A1C, and the incidence  of total joint arthroplasty infection. J Arthroplasty. 2012 May;27(5):726-9.e1. doi: 10.1016/j.arth.2011.09.013. Epub 2011 Nov 4. Kerkhoffs GM1, Servien E, Dunn W, Dahm D, Bramer JA, Haverkamp D. The influence of obesity on the complication rate and  outcome of total knee arthroplasty: a meta-analysis and systematic literature review. J Bone Joint Surg Am. 2012 Oct 17;94(20):1839-44. doi: 10.2106/JBJS.K.00820. Haverkamp D1, Klinkenbijl MN, Somford MP, Albers GH, van der Vis HM. Obesity in total hip arthroplasty--does it really matter?  A meta-analysis. Acta Orthop. 2011 Aug;82(4):417-22. doi: 10.3109/17453674.2011.588859. Epub 2011 Jun 10. Nguyen LC1, Sing DC1, Bozic KJ2. Preoperative Reduction of Opioid Use Before Total Joint Arthroplasty. J Arthroplasty. 2016  Sep;31(9 Suppl):282-7. doi: 10.1016/j.arth.2016.01.068. Epub 2016 Mar 17. Best MJ1, Buller LT1, Klika AK2, Barsoum WK2. Outcomes Following Primary Total Hip or  Knee Arthroplasty in Substance Misusers. J Arthroplasty. 2015 Jul;30(7):1137-41. doi: 10.1016/j.arth.2015.01.052. Epub 2015 Feb 7. Raphael IJ1, Tischler EH, Huang R, Rothman RH, Hozack WJ, Parvizi J. Aspirin: an alternative for pulmonary embolism  prophylaxis after arthroplasty? Clin Orthop Relat Res. 2014 Feb;472(2):482-8. doi: 10.1007/s11999-013-3135-z. Parvizi J1, Bloomfield MR. Multimodal pain management in orthopedics: implications for joint arthroplasty surgery.  Orthopedics. 2013 Feb;36(2 Suppl):7-14. doi: 10.3928/01477447-20130122-51. Auyong DB1, Allen CJ1, Pahang JA1, Clabeaux JJ1, MacDonald KM1, Hanson NA1. Reduced Length of Hospitalization in  Primary Total Knee Arthroplasty Patients Using an Updated Enhanced Recovery After Orthopedic Surgery (ERAS) Pathway. J Arthroplasty. 2015 Oct;30(10):1705-9. doi: 10.1016/j.arth.2015.05.007. Epub 2015 May 12. Austin MS, Urbani BT, Fleischman AN, Fernando ND, Purtill JJ, Hozack WJ, Parvizi J, Rothman RH. Formal Physical  Therapy After Total Hip Arthroplasty Is Not Required: A Randomized Controlled Trial. J Bone Joint Surg Am. 2017 Apr 19;99(8):648-655. doi: 10.2106/JBJS.16.00674. 24 Presentation Title 12 | [footer text here]