Hip and Knee Replacements · 2 | [footer text here] 3 Outline The Basics of Hip and Knee...

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12/2/2017

Derek Ward, M.D.Assistant Professor of Orthopaedic SurgeryDivision of Adult ReconstructionUniversity of California, San Francisco

Hip and Knee Replacements

What the PCP Needs to Know

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Disclosures

I have no disclosures


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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

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Utilization

By 2030:- 3.5 million TKA (673%)

- 570,000 THA (174%)


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Causes of Increased Utilization

Aging Population

Patients receiving arthroplasty at a younger age- Improvements in technology

- Obesity

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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


Presentation Title7

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

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Inflammatory Arthritis

Higher risk population

New perioperative medication recommendations


Presentation Title9

Trauma

Presentation Title10

Osteonecrosis

Steroids

HIV/HAART

Alcohol



Childhood Hip Disease

Developmental Dysplasia- Spectrum of Disease


What Surgeries Do We Perform? Knee arthroplasty

- Unicompartmental

- Primary/ Revision

Hip arthroplasty- Primary/ Revision

Hip arthroscopy – Usually Sports medicine

Knee arthroscopy - Usually sports medicine



What is Arthroplasty

“Arthro”- joint; “plasty”-reconstruction

Replacement of the diseased joint surface w/ a prosthesis (metal, plastic, ceramic)


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

Zimmer.com



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

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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


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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


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…..



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

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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”



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


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



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


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 patientsundergoing 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 incidenceof 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 Oct17;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 orKnee 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 embolismprophylaxis 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 PhysicalTherapy After Total Hip Arthroplasty Is Not Required: A Randomized Controlled Trial. J Bone Joint Surg Am. 2017 Apr19;99(8):648-655. doi: 10.2106/JBJS.16.00674.

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