Michael Tauton M.D. from the Mayo Clinic reviewed advancements in treatment of the arthritic knee in the January 15th 2020 issue of The Journal of Bone and Joint Surgery.
Non operative treatment recommendations have been outlined by the American Academy of Orthopedic Surgeons (AAOS). These include weight loss, use of anti-inflammatory meds (advil / aleve) or prescription alternatives, physical therapy, cortisone injections among others. If arthritis progresses and non-operative options fail then surgical treatments can be considered.
Types of Replacement
These include partial knee replacement which is an option for approximately 10% of patients. There are pros/cons with this procedure but a drawback is the higher failure rate in most reported series when compared with total knee replacement. Total Knee replacement (TKA) remains the gold standard for patients with end-stage arthritis with complete joint space loss and associated symptoms.
Modifiable Risk Factors
Once the decision to proceed with a TKA is made, alternative payment models and bundled payments have increased interest in optimization of patient's modifiable medical co-morbidities. These include: obesity, diabetes, high blood pressure, malnutrition, and kidney function among others. Getting these and other conditions addressed before surgery can minimize the risks of complications after surgery.
Anesthesia
Spinal anesthesia is preferred by the majority of Orthopedic Surgeons. In our practice 95% of patients receive a spinal plus a regional nerve block of the adductor canal which can provide up to 24 hours of help with post op pain. During surgery we also administer a pain cocktail in the tissue around the knee joint to further reduce post op pain.
Surgical Technique
The most common TKA technique uses traditional instruments to size and guide the operation. Computer assisted, patient specific cutting guides and robotic assisted techniques have been introduced over the last 20 years. We have reported our results with these techniques over the last 10 years. We are currently starting a newer generation of computer assisted surgery to hopefully improve the outcomes for our patients.
Wound Closure
We tailor our wound closure to your specific tissue requirements. Most people have a buried suture that does not have to be removed. This is covered by a waterproof layer and a skin glue. This stays in place for 2-3 weeks after surgery. Others with thinner skin may require skin staples which are removed 10-14 days post op.
Outpatient vs Inpatient
Medicare recently ruled that TKAs can be done in an outpatient facility. This is a rapidly evolving subject.
The majority of patients in the short term will be done as an overnight stay either in a hospital or ambulatory surgery center (ASC). Younger healthier patients can go home the day of surgery if certain criteria are met. Stay tuned this is evolving. Having your surgery at an ASC can have implications on your co-pay so be sure to check with your insurance carrier.
Post Op Physical Therapy (PT) and Going Home
Over 94% of our patients leave the hospital the day after surgery and go home. Several recent studies indicate that physical therapy as we have used it in the past may not be essential to a good outcome. There is a lot of work going on now to determine how much formal PT may be necessary for most patients. A key part to a good recovery is having a spouse, partner, sibling, and / or friend be available to help you the first week after surgery. That makes the transition from surgery to home easier.
Keys to a Good Outcome after TKA
Multiple factors influence the outcome of TKA. Having a dedicated caregiver be along with you on this journey, which means you have to plan ahead to make this happen. Optimizing modifiable risk factors. Selecting a high volume joint center and surgeon. Being an active partner in your care and recovery. Ask questions and be informed.