Hip and Knee Replacements What the PCP Needs to Know Derek Ward, - - PDF document

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Hip and Knee Replacements What the PCP Needs to Know Derek Ward, - - PDF document

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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 |

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12/2/2017

Derek Ward, M.D. Assistant Professor of Orthopaedic Surgery Division of Adult Reconstruction University 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
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Presentation Title 7

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

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Presentation Title 9

Trauma

Presentation Title 10

Osteonecrosis

  • Steroids
  • HIV/HAART
  • Alcohol
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Presentation Title 11

Childhood Hip Disease

  • Developmental Dysplasia
  • Spectrum of Disease

Presentation Title 12

What Surgeries Do We Perform?

  • Knee arthroplasty
  • Unicompartmental
  • Primary/ Revision
  • Hip arthroplasty
  • Primary/ Revision
  • Hip arthroscopy – Usually Sports medicine
  • Knee arthroscopy - Usually sports medicine
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Presentation Title 13

What is Arthroplasty

  • “Arthro”- joint; “plasty”-

reconstruction

  • Replacement of the

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

Presentation Title 14

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

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Presentation Title 15

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

Presentation Title 18

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…..
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Presentation Title 19

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”
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Presentation Title 21

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

Presentation Title 22

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

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Presentation Title 23

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

Presentation Title 24

References

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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 patients

undergoing total joint arthroplasty. J Arthroplasty. 2013 Sep;28(8 Suppl):25-9. doi: 10.1016/j.arth.2013.03.033. Epub 2013 Jul 30.

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