Disclosures Hip and Knee Replacements Paid teaching at the Depuy - - PowerPoint PPT Presentation

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12/13/2018

Derek Ward, M.D. Assistant Professor of Orthopaedic Surgery Division of Adult Reconstruction University of California, San Francisco

Hip and Knee Replacements

What’s New in 2018 and What the PCP Needs to Know

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Disclosures

• Paid teaching at the Depuy Fellows Course

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Outline

• Burden of Disease and Epidemiology
• The Basics of Hip and Knee Replacement
• What’s changed over the last decade
• Longevity
• Pain Management
• Hospital Stay
• Thromboembolism prophylaxis
• Risk Reduction

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First of all…

• THANK YOU!

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Presentation Title 5

Please Meet Rose

Question

What is the most common inpatient surgery performed in the US?

A.

Percutaneous coronary angioplasty

B.

Total hip replacement

C.

Lumbar Laminectomy

D.

Appendectomy

E.

Total Knee Replacement

6 Prese ntatio n Title

5% 38% 49% 7% 1%

Presentation Title 7 8

Burden of Disease

• Arthritis is the most common cause of disability in the US
• 22.7% of adults have doctor-diagnosed arthritis
• 43.2% of patients with arthritis report activity limitations due to

disease

• Cost estimates (2003) = $128 Billion, 1.2% of GDP

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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 Title 12

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
• Brings in other issues
• Unnecessary treatment

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Knee Arthritis

• X-ray
• Clinical

Presentation Title 14

Hip Arthritis

• X-ray
• Clinical

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Inflammatory Arthritis

• Autoimmune
• Higher risk population
• New perioperative

medication recommendations

Presentation Title 16

Trauma

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Presentation Title 17

Osteonecrosis

• Steroids
• HIV/HAART
• Alcohol

Presentation Title 18

Childhood Hip Disease

• Developmental Dysplasia
• Spectrum of Disease

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What Surgeries Do We Perform?

• Knee arthroplasty
• Unicompartmental
• Primary/ Revision
• Hip arthroplasty
• Primary/ Revision
• Hip arthroscopy – Usually Sports medicine
• Knee arthroscopy - Usually sports medicine

Presentation Title 20

What is Arthroplasty

• “Arthro”- joint; “plasty”-

reconstruction

• Replacement of the

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

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High-Impact Intervention

Presentation Title 22 Presentation Title 23

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

Presentation Title 24

THA

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Presentation Title 25

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

Presentation Title 26

TKA

Presentation Title 27

Unicompartmental Knee Arthroplasty (UKA)

Presentation Title 28

Revision TKA

• Infection
• Loosening
• Fracture
• Instability

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Presentation Title 29

Revision THA

• Infection
• Loosening
• Fracture
• Dislocation

Question

You have a 45 year old otherwise healthy patient with moderate knee arthritis who has failed oral NSAIDS and Tylenol, physical therapy, bracing, and

• injections. What do you tell them?

A.

“Hang in there as long as you can and deal with the pain until you are 65”

B.

“I would like to refer you to a surgeon to discuss your

• ptions”

C.

“Let start you on a little bit of Percocet”

D.

”I know a great stem cell guy….he’s relatively cheap”

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5% 5% 1% 90%

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Changes in Arthroplasty

• Longevity
• Too young for arthroplasty?
• 50s?
• 40s?
• 30?s….
• Quality of life decision/balance
• Approximately 1% failure rate

per year for any reason

• Change in expectations
• Changes in implant technology

https://www.waterskimag.com/features/2015/04/08/joint-replacement-doesnt-have-to-end-your-skiing-life#page-2

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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

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Changes in Arthroplasty – Pain Management

• Multi-modal, non-opiate based regimen
• Spinal anesthesia
• Regional nerve blocks/catheters
• 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…..
• Surgeons are well aware of the role we play in the opioid

crisis

Question

What is the appropriate chemical DVT prophylaxis for a 68 year old

• therwise healthy female undergoing joint replacement?

A.

Coumadin with a goal INR of 2-3 x 6 weeks

B.

Apixaban 5mg Daily

C.

Enoxaparin 30mg BID

D.

Aspirin 81mg BID

E.

No chemical prophylaxis needed

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3% 18% 21% 29% 29%

Presentation Title 35

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
• Xa inhibitors =? Infection risk

Question

What is the appropriate antibiotic prophylaxis for a 68 year old

• therwise healthy female undergoing a routine cleaning 3 months

postoperatively?

A.

Keflex 500mg PO q6 x 1 week

B.

Doxycycline 100mg PO BID x 4 days

C.

Amoxicillin 500mg PO BID x 2 doses

D.

No antibiotic prophylaxis needed

E.

Z-pac

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1% 1% 1% 78% 20%

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Dental Prophylaxis

“Doc, do I need antibiotics before I get my teeth cleaned”

• Bottom line….we don’t know if this makes any different
• ADA recommendations, 2015

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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
• MOST patients go home (>90%)
• ERAS = “Enhanced Recovery After Surgery”
• Protocols throughout the episode of care
• There is a large move towards outpatient surgery, including in

the Medicare population

• Removal of TKA from inpatient only list in 2018

Presentation Title 39

Our Protocol

Outpatient assessment Outpatient assessment

• Candidate for TKA/THA,

meets with Nurse Navigator

Preoperative class Preoperative class

• Online/App patient

engagement tool

Preoperative anesthesia Assessment Preoperative anesthesia Assessment

• Email/EMR

communication with surgeon/team

Surgery Surgery

• Protocol Pain Control,

Risk stratified DVT prophylaxis

Day of Surgery Assessment by PT/OT Day of Surgery Assessment by PT/OT Discharge Home POD#0

• r 1

Discharge Home POD#0

• r 1
• Most patients have Home

Health PT, then Outpatient PT

4-6 Week FU 4-6 Week FU

• Continuous check-in

with app/online engagement platform Presentation Title 40

Changes in Arthroplasty – Risk Reduction

• Diabetes
• HgBA1c < 8
• Smoking
• No nicotine
• Obesity
• BMI < 40
• Chronic Pain
• Opiates – decrease dose by 50%
• Substance abuse
• Minimum documented sobriety period

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Other Questions/Myths

• Platelet Rich Plasma and

Stem Cells for arthritis

• Rejection and Metal Allergies
• Gender Specific Implants
• Minimally Invasive Surgery
• Navigation/Robotics/Computer

Assisted

http://www.smartchoicestemcell.com/about- us/cost-and-financing.aspx

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When Bad Things Happen…

• Low Complication

rate….but....

• Certain complications are

devastating and easier to fix if diagnosed early.

• Don’t hesitate to refer any

patient with new mechanical symptoms or pain after a hip

• r knee replacement

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Periprosthetic Infection

• This is absolutely devastating (extremely high morbidity and

mortality)

• Better if caught early, Almost always requires surgeries (often

multiple surgeries)

• May also require prolonged and even lifelong antibiotics
• We have dramatically reduced the incidence of every

complication in the last decade….except this one

• Obesity
• Difficulty of eradication

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Conclusions

• Hip and Knee Arthroplasty are rapidly expanding procedures

with excellent long term outcomes

• Recovery is becoming significantly easier
• Help us modify the risk factors that we can before surgery
• Rapid referral for patients with painful joint replacements

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Thank you!