Outcomes in Total Knee Replacement: Its in your hands! Douglas E - - PowerPoint PPT Presentation

Outcomes in Total Knee Replacement: “It’s in your hands!”

Douglas E Padgett, MD Chief, Adult Reconstruction and Joint Replacement Hospital For Special Surgery New York, NY

Disclosures

Consultant:

– DJO Global: Hip Products – PixarBio: biopharma company

Validated the HOOS Jr, and KOOS Jr. rating instruments: NO $$$ ! Research Support: Trump Institute Boards:

– Hip Society – American Joint Replacement Registry – Journal of Arthroplasty

Special Thanks

What to speak about ?

Why not ?

Boring, Pedantic, Useless

I turned to my yogi for spiritual guidance and inspiration:

Observations on Outcomes after Total Knee

It’s in your hands !

What do we want after TKR ?

A happy patient ! No complications ! A simple thanks !

What do the patients want ?

Now that’s a great question ! We all think that it’s simply

– Pain relief – Improvement in function – A better life style

The Millennial Patient

Millennial Misperception about TKR

“It can’t be that big a deal, they do it as

• utpatients !”

“I had my knee scoped a few years back, how bad could this be” “I had a friend who had a knee and he was back at work in 3 days”

“Back in the Game”

In reality, TKR is more like this !

My personal strategy to get a better outcome !

Focus on the things that work Forget about the things that :

– Don’t work – Can’t work – Won’t work

The Things That Work

Patient Selection Technical Execution Perioperative / Postop Mgt

How to achieve success ? Step 1

Patient selection

– Make sure the patient has arthritis – Make sure the symptoms fit the clinical picture

Patient Selection

Make sure the patient has arthritis!

Patient Selection

Patient Selection

Patient Selection

Inferior outcomes

– 1700 TKR’s – 44 pt’s with Kellegren Lawrence score 2 or less – Significantly lower knee scores – Dissatisfaction rate: 32% – 18% reoperation rate

Peck et al, Knee 2014

Lessons learned: Examine hip & knee !

Patient Selection: Disability

Level of disability:

– How best assess ?

Validated measures:

– WOMAC – KOOS – KOOS Jr

7 questions:

– Stiffness – 4 questions pain

Twist Straightening Stairs standing

– Function

Rising from sitting Bending to floor

Patient Selection: Disability

KOOS Jr. Survey results Mild stiffness Mild pain Still plays golf I don’t care what his xray looks like: I’m not

• perating !!

Patient Selection: Evidence for Disability

HSS Registry data:

– 2300 TKR’s – PROM’s including patient satisfaction collected

2 yr results

– Greatest satisfaction in patients with more pain, worse function but ….general health still good: most likely to be satisfied !

Maratt et al J Arthroplasty 2015

Patient Selection: Review of Risk Factors

The “modifiable” risk factors The “not so modifiable” risk factors

Patient Selection: Modifiable Risk Factors

Risk Factors:

– Usual suspects:

Diabetes Obesity Smoking Cardiopulmonary Disease Prior history of VTE

Patient Selection: How to handle ?

Diabetes:

– Evidence is clear:

HgbA1c < 8.0

Smoking:

– Clear:

STOP !

Cardiac Disease

– Optimize

VTE history:

– Get your consults – Bleeding vs VTE discussion

Patient Selection: The Obesity Dilemma

Numerous studies demonstrate obese patients have improved outcomes after TJR !

– London group:

Super obese improvement = normal weight group!

Anecdotally, they are among our most appreciative patients !

Rajgopal et al, JBJS 2013

Patient Selection: So you can do it? Do you want to?

Patient Selection: The Obesity Dilemma

How many more articles do we need to demonstrate the linear relationship between obesity and the risk of complications ?

Obesity and TKR:

It’s your personal decision

Patient Selection: The “not so modifiable risks”

The depressed or major psychiatric disorder patient The narcotic dependent patient The “just plain pain in the ass patient”

Patient Selection: The Depressed Patient

Data is quite concerning:

– Study out of Berlin:

150 pt’s undergoing TKR evaluated with Patient Health Quest.

– Pain and somatization were assessed

At 1 yr: pt’s with depressive symptoms had higher pain scores / lower knee function and worse satisfaction

Patient Selection: The Depressed Patient

Good News:

– Recent 1 and 5 yr study of 266 patients

At 1 yr, anxiety / depression led to worse WOMAC and KSS scores However, at 5 yrs, those patients were found to be at the same level of function and same pain/satisfaction as the non- psychosocial group

Proceed with caution!

Wylde et al, Acta Ortho 2017

Patient Selection: The Opioid User

Data from the Brigham is clear:

– 156 TKR’s – Preop opioid use of at least 1 script – Greater preop pain in

• pioid group

– Greater postop pain – Worse WOMAC improvement

Smith, Katz, Losina; JBJS 2017

Patient Selection: The Opioid User

Strategies:

– Intervene with pain management – Even if the patient can’t be weaned, at least they can map out an after surgery program – ? Contract for pain management beyond 8-12 weeks

Patient Selection: The Sociopath

You’ll never change their behaviour. They can be an emotional sink-hole for your practice. DEP’s rules:

– Never insult / demean any member of the team. – If you do, you’re out !

Older I get, less tolerant of these folks.

Things that Work: Technical Execution

Technical Execution

Practice the basics:

– Surgical Exposure is paramount !

The data on MIS TKR is weak (at best) You can’t kill what you can’t see !

Things that Work: Technical Execution

Cut the tibia at 90 degrees I suppose if you cut it in varus, you can always convince yourself that it is kinematically aligned !

Technical Execution: The Varus Tibia Consequence

Merrill Ritter:

– “a varus tibia will kill you” – Highest risk for loosening / failure

HSS Retrieval Data

– Varus tibial alignment associated with increased damage modes of pitting, delamination

Zi et al, CORR 2017

Things that Work: Technical Execution

Practice the basics: – Understand the deformity: – What is tight ? – What is loose ? – How to get them balanced ? What soft tissues can do ? What can “realignment do ?

Get Comfortable with Releases (regardless of technique)

Technical Execution: Get Rotation Correct

Technical Execution: The Patella

Decide if you want to resurface:

– Factors:

Age of patient ? Accept some anterior knee pain You live in a city where you won’t get thrown under the bus

Do it correctly !

Things that Matter !

Perioperative Postoperative Mgt.

Perioperative Things that Matter

Tranexamic Acid

– Not a pro-coagulant ! – An anti fibrinolytic ! – A GAME CHANGER !

Less blood loss Less draining wounds Lower transfusion rates Lower infection rates

IV / Topical / Oral

– ? Optimal dose / route ?

Perioperative Things that Matter Pain Protocols

Pre-emptive:

– Steroids – Anti-emetics

Pain Protocols

Better Press Ganey Scores Improved patient satisfaction Opportunity to work with your anesthesia team

Postop Things that Matter: Rehab

Mobility after TKR

– Controversial ? – Perhaps ! – Hard to argue that a mobility program won’t benefit the patient

Ideal method to employ:

– Prehab: some data even 1 visit helps

More than this: No effect !

– Postop:

Self vs facility ?

Postop Things That Matter: Rehabilitation

Patients convinced it’s essential ! If you are in bundle:

– Have to keep an eye

• n usage

PT’s can be your eyes / ears Outline a weaning program:

– Self directed gym – “silver sneakers”

Things That Don’t Impact Outcomes

Type of Implant

Sorry !

Which Implant Should I Get ?

“the 30 year knee?” “the knee that goes around?” “I’m a woman, maybe I should have one of the ladies knees?”

“I want this implant because it ……”

“I’ve heard …..” “I’ve read ……” “My daughters hairdressers brother had a knee replacement and he is doing great”

Is there a “best in class implant”

What Data Can You Use ?

Registry Data

Good validity especially in countries with NHS Excellent for tracking revisions but ….exact reason for failure may not be clear !

Australian Registry 2017: Challenges

516 different prostheses types / combinations 114 prostheses types with > 400 procedures In general, lowest revision rate NexGen for both cemented / c’less

Confidence levels wide

Registry Limitations

It doesn’t give you any functional information Its largely

– descriptive – survivorship

Effect of Implant Design on Functional Outcomes

ARHQ grant: 2007-11 Prospectively enrolled all TJR’s HSS

– Baseline CCI, BMI, ASA classification

Followed for:

– 6 month complication – 2 year / 5 year

• utcomes

KOOS, LEAS, SF 12 Expectations Satisfaction

Research Question: Does Implant Design Matter?

54 Surgeons All fellowship trained:

– Adult Recon or Sports Medicine – Only PS Implants – 5 Most commonly used implants

(for statistical purposes)

– NexGen – Exactech – Depuy – Smith / Nephew – Biomet

Does Implant Design Matter?

Among the 5 groups

• f implants:

– NexGen had worse preop pain and function – Exactech patients were healthier – The others: somewhat in between !

Results

4100 TKR’s

• 6
• 4
• 2

2 4 6 8 Vanguard Sigma OptetrakLogic Genesis II NexGen Change in KOOS Value Implant group Pain Stiffness ADL Sports and Rec QOL

Implant Design on Function

The Zimmer NexGen had highest KOOS scores and satisfaction The Optetrak had lowest scores for pain, stiffness, sports, & satisfaction

Implant Design on Outcome No practical Difference !

But……the magnitude of the difference in all KOOS domains was 4 points or less ! Minimally clinical important differences of 8-10 points is considered relevant ! ** No difference in outcome whether surgery done by Sports Medicine or Adult Reconstruction ! (ouch!)

Things that don’t matter:

Discharge Destination

Role of Rehabilitation after TKR

Historically accepted although many unknowns:

– What to do ? – How often to do ? – Where to do ?

In patient rehab facility Home physical therapy Out patient physical therapy

Role of In patient rehab and TKR recovery ?

Very little data available Mahomed et al performed at RCT of 234 patients

– Home vs In-patient – Primary TKR or THR – Did not control for co- morbidities

Results:

– Trend for increase PJI rate in the in-patient rehab group – Significant cost increase in the in patient rehab group – No difference in clinical outcomes

Mahomed et al JBJS 2008

But in the US, we really didn’t care where patients went after surgery !

2012: Era of Value Based Purchasing “Bundled Payment for Care Improvement” 90 Day Episode of Care (in US $ 2012)

Facility IP consult Anesthesia Surgeon Post Acute Care Total Episode 15,897 345 469 1750 11,719 30,180

39% of bundle is in after care !!! Potential opportunity ?????

Methods

Joint Replacement Registry at HSS Used cohort from 2007-2011 supported by funding thru AHRQ grant Prospective enrollment of all TKR’s performed Data Collected

– Preop Baseline

Pt characteristics Pt co morbidities

– 6 month:

Complication data including manipulation

– 2 year data

WOMAC SF-12 LEAS Patient satisfaction

Methods

8145 unilateral TKR’s

– 4477 to rehab – 3011 to home – 657 to skilled nursing facility (SNF) – Destination largely self selected !

Due to confounding variables, direct group to group comparison not valid!

Methods: Propensity Score matching algorithm

Adjusts for differences in baseline characteristics:

– Age, gender – Co-morbidities – Payer mix – Living situation (alone etc) – Surgeon

Propensity Score:

– Reflects the probablity

• f discharge

destination – Balances potential confounding characteristics – Regression analysis performed to adjust for residual confounding variables

Results: Home vs Rehab

6 Month complication rate:

– Higher Fx rate in rehab group (0.7% vs 0.1%) (p=0.038) – NO difference in manipulation rates (4%)

Functional Results: Inpatient (blue) vs Home (green)

No significant differences were found

• Better WOMAC pain delta in home

group (p=0.0014), ?? clinically meaningful

Functional Results: Inpatient (blue) vs Home (green)

• Better WOMAC function delta

in home group (p=0.0125) ?? clinically meaningful

• Better LEAS delta in home

group (p=0.0046) ?? clinically meaningful

Discussion

Our results clearly demonstrate:

– Discharge to home is:

Safe No compromise to early functional recovery (same manipulation rate) Intermediate term pain and functional results comparable to those going to rehab facility

Successful Outcomes after TKR

Starts with patient selection

– Pick the right patient

Execute the operation correctly:

– Alignment / Balance

Use a system you like:

– Familiarity – comfort

Employ modern periop measures

– Blood conservation – Perioperative pain

Guide the patient in the recovery process

– Targeted therapy – Judicious use of rehab facilities

“It’s in your Hands”

Final tribute to Yogi !

Thank You