CME
Advances in total knee arthroplasty Wade D. Aumiller, PhD; Harry Anderson Dollahite, MD
ABSTRACT Total knee arthroplasty (TKA) is one of the success stories of modern surgery. Primary TKA is commonly used when nonsurgical treatments for osteoarthritis fail. The need for TKA is projected to increase by 673% between 2005 and 2030, creating a tremendous burden on the healthcare system. This article reviews selected perioperative management strategies, computer-aided navigation, patient-specific cutting blocks, and medial pivot knee implants as potential sources of improvements in clinical efficiency and patient outcomes. Keywords: total knee arthroplasty, patient-specific cutting blocks, intra-articular injection, medial pivot knee, tranexamic acid, cyclokapron
Learning objectives
© THE SCIENCE PICTURE COMPANY / PHOTOTAKE
Compare methods of bleeding control and pain management for patients undergoing TKA. Discuss results of studies comparing TKA intraoperative mechanical implements and technical methods, including computer-aided navigation, patient-specific cutting blocks, and the medial pivot knee.
T
otal knee arthroplasty (TKA) is one of the success stories of modern surgery, providing high patient satisfaction outcomes despite the high volume. Primary TKA is most frequently used to treat advanced osteoarthritis in one or more of the three knee compartments: medial femoral-tibial, lateral femoral-tibial, or femoral-patellar.1 TKA may be considered when nonsurgical treatments fail and the patient’s knee pain significantly impairs activities of daily living (ADLs). TKA also may be used in patients with rheumatoid arthritis or traumatic osteoarthritis caused by lower extremity trauma.2,3 However, careful patient selection is advised in these populations because of the increased risk for poor TKA outcomes. Wade D. Aumiller is a PA student at the University of Texas Rio Grande Valley in Edinburg, Tex. Harry Anderson Dollahite practices orthopedics in Fort Worth, Tex. The authors have disclosed no potential conflicts of interest, financial or otherwise. DOI: 10.1097/01.JAA.0000480563.76217.ae Copyright © 2016 American Academy of Physician Assistants
Demand for TKA is expected to grow 673% between 2005 and 2030, putting a tremendous strain on the healthcare system.4 Medicare pays for about 60% of total joint arthroplasties in the United States.5 However, the current US healthcare payment system is unsustainable. Because of the expected increase in TKA cases, evaluating new technologies is key to improving clinical efficiency and patient outcomes, and to justify increased costs. This article reviews current literature for significant findings in TKA perioperative management, computer-aided navigation, patientspecific cutting blocks, and the medial pivot knee.
JAAPA Journal of the American Academy of Physician Assistants
Copyright © 2016 American Academy of Physician Assistants
www.JAAPA.com
27
CME
Key points Tranexamic acid (IV or topical) is an effective hemostasis agent for use in orthopedic surgeries. Periarticular injections of a mixture of ropivacaine, morphine, betamethasone, and epinephrine mixture following TKA have been shown to significantly reduce patients’ need for postoperative analgesia. Home telerehabilitation following TKA has been shown to be a viable alternative to conventional TKA rehabilitation and yields comparable results. Patient-specific cutting blocks present a compromise between conventional TKA and computer-aided navigation TKA. Studies indicate measureable OR time savings. Medial pivot knee systems may help restore natural knee motion and reduce postoperative pain.
PERIOPERATIVE MANAGEMENT Managing a patient’s response to the stress of surgery can increase the chances of a favorable postoperative outcome.6,7 Reducing blood loss Aguilera and colleagues studied the use of IV tranexamic acid, an antifibrinolytic drug, in patients undergoing revision TKAs.8 They found that relative to controls, patients who received tranexamic acid had significantly reduced blood loss (P=0.015), although their need for transfusion was not significantly lower (P=0.057).8 MacGillivray and colleagues examined the effectiveness of a two-dose IV tranexamic acid regimen in two groups of patients who had bilateral TKA.9 Mean blood loss for those who received 15 mg/kg of tranexamic acid was 462 mL compared with 918 mL for patients who received placebo (P
Advances in total knee arthroplasty Wade D. Aumiller, PhD; Harry Anderson Dollahite, MD
ABSTRACT Total knee arthroplasty (TKA) is one of the success stories of modern surgery. Primary TKA is commonly used when nonsurgical treatments for osteoarthritis fail. The need for TKA is projected to increase by 673% between 2005 and 2030, creating a tremendous burden on the healthcare system. This article reviews selected perioperative management strategies, computer-aided navigation, patient-specific cutting blocks, and medial pivot knee implants as potential sources of improvements in clinical efficiency and patient outcomes. Keywords: total knee arthroplasty, patient-specific cutting blocks, intra-articular injection, medial pivot knee, tranexamic acid, cyclokapron
Learning objectives
© THE SCIENCE PICTURE COMPANY / PHOTOTAKE
Compare methods of bleeding control and pain management for patients undergoing TKA. Discuss results of studies comparing TKA intraoperative mechanical implements and technical methods, including computer-aided navigation, patient-specific cutting blocks, and the medial pivot knee.
T
otal knee arthroplasty (TKA) is one of the success stories of modern surgery, providing high patient satisfaction outcomes despite the high volume. Primary TKA is most frequently used to treat advanced osteoarthritis in one or more of the three knee compartments: medial femoral-tibial, lateral femoral-tibial, or femoral-patellar.1 TKA may be considered when nonsurgical treatments fail and the patient’s knee pain significantly impairs activities of daily living (ADLs). TKA also may be used in patients with rheumatoid arthritis or traumatic osteoarthritis caused by lower extremity trauma.2,3 However, careful patient selection is advised in these populations because of the increased risk for poor TKA outcomes. Wade D. Aumiller is a PA student at the University of Texas Rio Grande Valley in Edinburg, Tex. Harry Anderson Dollahite practices orthopedics in Fort Worth, Tex. The authors have disclosed no potential conflicts of interest, financial or otherwise. DOI: 10.1097/01.JAA.0000480563.76217.ae Copyright © 2016 American Academy of Physician Assistants
Demand for TKA is expected to grow 673% between 2005 and 2030, putting a tremendous strain on the healthcare system.4 Medicare pays for about 60% of total joint arthroplasties in the United States.5 However, the current US healthcare payment system is unsustainable. Because of the expected increase in TKA cases, evaluating new technologies is key to improving clinical efficiency and patient outcomes, and to justify increased costs. This article reviews current literature for significant findings in TKA perioperative management, computer-aided navigation, patientspecific cutting blocks, and the medial pivot knee.
JAAPA Journal of the American Academy of Physician Assistants
Copyright © 2016 American Academy of Physician Assistants
www.JAAPA.com
27
CME
Key points Tranexamic acid (IV or topical) is an effective hemostasis agent for use in orthopedic surgeries. Periarticular injections of a mixture of ropivacaine, morphine, betamethasone, and epinephrine mixture following TKA have been shown to significantly reduce patients’ need for postoperative analgesia. Home telerehabilitation following TKA has been shown to be a viable alternative to conventional TKA rehabilitation and yields comparable results. Patient-specific cutting blocks present a compromise between conventional TKA and computer-aided navigation TKA. Studies indicate measureable OR time savings. Medial pivot knee systems may help restore natural knee motion and reduce postoperative pain.
PERIOPERATIVE MANAGEMENT Managing a patient’s response to the stress of surgery can increase the chances of a favorable postoperative outcome.6,7 Reducing blood loss Aguilera and colleagues studied the use of IV tranexamic acid, an antifibrinolytic drug, in patients undergoing revision TKAs.8 They found that relative to controls, patients who received tranexamic acid had significantly reduced blood loss (P=0.015), although their need for transfusion was not significantly lower (P=0.057).8 MacGillivray and colleagues examined the effectiveness of a two-dose IV tranexamic acid regimen in two groups of patients who had bilateral TKA.9 Mean blood loss for those who received 15 mg/kg of tranexamic acid was 462 mL compared with 918 mL for patients who received placebo (P
