Outcomes in Total Knee Replacement: “It’s in your hands!” Douglas E Padgett, MD Chief, Adult Reconstruction and Joint Replacement Hospital For Special Surgery New York, NY
Disclosures Consultant: – DJO Global: Hip Products – PixarBio: biopharma company Validated the HOOS Jr, and KOOS Jr. rating instruments: NO $$$ ! Research Support: Trump Institute Boards: – Hip Society – American Joint Replacement Registry – Journal of Arthroplasty
Special Thanks
What to speak about ?
Why not ? Boring, Pedantic, Useless
I turned to my yogi for spiritual guidance and inspiration:
Observations on Outcomes after Total Knee It’s in your hands !
What do we want after TKR ? A happy patient ! No complications ! A simple thanks !
What do the patients want ? Now that’s a great question ! We all think that it’s simply – Pain relief – Improvement in function – A better life style
The Millennial Patient
Millennial Misperception about TKR “It can’t be that big a deal, they do it as outpatients !” “I had my knee scoped a few years back, how bad could this be” “I had a friend who had a knee and he was back at work in 3 days”
“Back in the Game”
In reality, TKR is more like this !
My personal strategy to get a better outcome ! Focus on the things that work Forget about the things that : – Don’t work – Can’t work – Won’t work
The Things That Work Patient Selection Technical Execution Perioperative / Postop Mgt
How to achieve success ? Step 1 Patient selection – Make sure the patient has arthritis – Make sure the symptoms fit the clinical picture
Patient Selection Make sure the patient has arthritis!
Patient Selection
Patient Selection
Patient Selection Inferior outcomes – 1700 TKR’s – 44 pt’s with Kellegren Lawrence score 2 or less – Significantly lower knee scores – Dissatisfaction rate: 32% – 18% reoperation rate Peck et al, Knee 2014
Lessons learned: Examine hip & knee !
Patient Selection: Disability Level of disability: 7 questions: – How best assess ? – Stiffness – 4 questions pain Twist Validated measures: Straightening – WOMAC Stairs – KOOS standing – KOOS Jr – Function Rising from sitting Bending to floor
Patient Selection: Disability KOOS Jr. Survey results Mild stiffness Mild pain Still plays golf I don’t care what his xray looks like: I’m not operating !!
Patient Selection: Evidence for Disability HSS Registry data: – 2300 TKR’s – PROM’s including patient satisfaction collected 2 yr results – Greatest satisfaction in patients with more pain, worse function but ….general health still good: most likely to be satisfied ! Maratt et al J Arthroplasty 2015
Patient Selection: Review of Risk Factors The “modifiable” risk factors The “not so modifiable” risk factors
Patient Selection: Modifiable Risk Factors Risk Factors: – Usual suspects: Diabetes Obesity Smoking Cardiopulmonary Disease Prior history of VTE
Patient Selection: How to handle ? Diabetes: – Evidence is clear: HgbA1c < 8.0 Smoking: – Clear: STOP ! Cardiac Disease – Optimize VTE history: – Get your consults – Bleeding vs VTE discussion
Patient Selection: The Obesity Dilemma Numerous studies demonstrate obese patients have improved outcomes after TJR ! – London group: Super obese improvement = normal weight group! Anecdotally, they are among our most Rajgopal et al, JBJS 2013 appreciative patients !
Patient Selection: So you can do it? Do you want to?
Patient Selection: The Obesity Dilemma How many more articles do we need to demonstrate the linear relationship between obesity and the risk of complications ?
Obesity and TKR: It’s your personal decision
Patient Selection: The “not so modifiable risks” The depressed or major psychiatric disorder patient The narcotic dependent patient The “just plain pain in the ass patient”
Patient Selection: The Depressed Patient Data is quite concerning: – Study out of Berlin: 150 pt’s undergoing TKR evaluated with Patient Health Quest. – Pain and somatization were assessed At 1 yr: pt’s with depressive symptoms had higher pain scores / lower knee function and worse satisfaction
Patient Selection: The Depressed Patient Good News: – Recent 1 and 5 yr study of 266 patients At 1 yr, anxiety / depression led to worse WOMAC and KSS scores However, at 5 yrs, those patients were found to be at the same level of function and same pain/satisfaction as the non- psychosocial group Wylde et al, Acta Ortho 2017 Proceed with caution!
Patient Selection: The Opioid User Data from the Brigham is clear: – 156 TKR’s – Preop opioid use of at least 1 script – Greater preop pain in opioid group – Greater postop pain – Worse WOMAC improvement Smith, Katz, Losina; JBJS 2017
Patient Selection: The Opioid User Strategies: – Intervene with pain management – Even if the patient can’t be weaned, at least they can map out an after surgery program – ? Contract for pain management beyond 8-12 weeks
Patient Selection: The Sociopath You’ll never change their behaviour. They can be an emotional sink-hole for your practice. DEP’s rules: – Never insult / demean any member of the team. – If you do, you’re out ! Older I get, less tolerant of these folks.
Things that Work: Technical Execution
Technical Execution Practice the basics: – Surgical Exposure is paramount ! The data on MIS TKR is weak (at best) You can’t kill what you can’t see !
Things that Work: Technical Execution Cut the tibia at 90 degrees I suppose if you cut it in varus, you can always convince yourself that it is kinematically aligned !
Technical Execution: The Varus Tibia Consequence Merrill Ritter: – “a varus tibia will kill you” – Highest risk for loosening / failure HSS Retrieval Data – Varus tibial alignment associated with increased damage modes of pitting, delamination Zi et al, CORR 2017
Things that Work: Technical Execution Practice the basics: – Understand the deformity: – What is tight ? – What is loose ? – How to get them balanced ? What soft tissues can do ? What can “realignment do ?
Get Comfortable with Releases (regardless of technique)
Technical Execution: Get Rotation Correct
Technical Execution: The Patella Decide if you want to resurface: – Factors: Age of patient ? Accept some anterior knee pain You live in a city where you won’t get thrown under the bus Do it correctly !
Things that Matter ! Perioperative Postoperative Mgt.
Perioperative Things that Matter Tranexamic Acid – Not a pro-coagulant ! – An anti fibrinolytic ! – A GAME CHANGER ! Less blood loss Less draining wounds Lower transfusion rates Lower infection rates IV / Topical / Oral – ? Optimal dose / route ?
Perioperative Things that Matter Pain Protocols Pre-emptive: – Steroids – Anti-emetics
Pain Protocols Better Press Ganey Scores Improved patient satisfaction Opportunity to work with your anesthesia team
Postop Things that Matter: Rehab Mobility after TKR – Controversial ? – Perhaps ! – Hard to argue that a mobility program won’t benefit the patient Ideal method to employ: – Prehab: some data even 1 visit helps More than this: No effect ! – Postop: Self vs facility ?
Postop Things That Matter: Rehabilitation Patients convinced it’s essential ! If you are in bundle: – Have to keep an eye on usage PT’s can be your eyes / ears Outline a weaning program: – Self directed gym – “silver sneakers”
Things That Don’t Impact Outcomes
Type of Implant Sorry !
Which Implant Should I Get ? “the 30 year knee?” “the knee that goes around?” “I’m a woman, maybe I should have one of the ladies knees?”
“I want this implant because it ……” “I’ve heard …..” “I’ve read ……” “My daughters hairdressers brother had a knee replacement and he is doing great”
Is there a “best in class implant”
What Data Can You Use ?
Registry Data Good validity especially in countries with NHS Excellent for tracking revisions but ….exact reason for failure may not be clear !
Australian Registry 2017: Challenges 516 different prostheses types / combinations 114 prostheses types with > 400 procedures In general, lowest revision rate NexGen for both cemented / c’less Confidence levels wide
Registry Limitations It doesn’t give you any functional information Its largely – descriptive – survivorship
Recommend
More recommend
