Hip and Knee Replacements

Transcription

1 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]

2 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: million TKA (673%) - 570,000 THA (174%) 4 2 [footer text here]

3 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]

4 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 Inflammatory Arthritis Higher risk population New perioperative medication recommendations 8 4 [footer text here]

5 Trauma 9 Osteonecrosis Steroids HIV/HAART Alcohol 10 5 [footer text here]

6 Childhood Hip Disease Developmental Dysplasia - Spectrum of Disease 11 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 6 [footer text here]

7 What is Arthroplasty Arthro - joint; plasty - reconstruction Replacement of the diseased joint surface w/ a prosthesis (metal, plastic, ceramic) 13 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 Zimmer.com 7 [footer text here]

8 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 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]

9 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 [footer text here]

10 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 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 [footer text here]

11 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 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 [footer text here]

12 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 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 Dec;19(12): Springer BD1. Modifying Risk Factors for Total Joint Arthroplasty: Strategies That Work Nicotine. J Arthroplasty Aug;31(8): doi: /j.arth 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 Sep;28(8 Suppl):25-9. doi: /j.arth 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 May;27(5):726-9.e1. doi: /j.arth 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 Oct 17;94(20): doi: /JBJS.K 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 Aug;82(4): doi: / Epub 2011 Jun 10. Nguyen LC1, Sing DC1, Bozic KJ2. Preoperative Reduction of Opioid Use Before Total Joint Arthroplasty. J Arthroplasty Sep;31(9 Suppl): doi: /j.arth 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 Jul;30(7): doi: /j.arth 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 Feb;472(2): doi: /s z. Parvizi J1, Bloomfield MR. Multimodal pain management in orthopedics: implications for joint arthroplasty surgery. Orthopedics Feb;36(2 Suppl):7-14. doi: / 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 Oct;30(10): doi: /j.arth 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 Apr 19;99(8): doi: /JBJS [footer text here]