Advances in Total Knee

Arthroplasty

Jared Brummel, DOOrthopedic Surgeon

Objectives

1. Discuss the impact of patient selection for total knee arthroplasty and its impact on outcomes

2. Describe the materials and surgical techniques of partial and total knee arthroplasty

Outline

1. Indications and Eligibility Requirements2. Surgical Technique3. Total vs. Partial Knee Replacement4. Managing Post Surgical Pain5. Outcome Data

Advances in Knee ArthroplastyTraditional Recent Advances5-day hospital stay Typically go home next day3-month recovery time Walking day of surgery~ 12-inch incision ~ 3-4 inch incisionLarge scar Smaller and less noticeable scarsSurgeon can fully see knee joint Surgeon can fully see knee jointSevere disruption of muscles and tissue

Less disruption of muscles and tissue

Bearing materials prone to corrosion and/or squeaking

Advances allow for reliable materials that last longer

5

Indications and Eligibility Requirements

Assessing the Patient’s Pain• Does your knee hurt one or more days per week?• Does the pain interfere with your sleep?• Is it painful for you to walk more than a block?• Are pain medications no longer working?• Is knee pain limiting your participation in activities

(e.g. family vacations or other functions)?• Has inactivity from knee pain caused you to gain

weight?

Conservative Treatment Options• Water therapy

– Soaking, ice packs, hot packs• Exercise & physical therapy

– Also good for weight loss• Medications

– Analgesics (NSAIDS)– Corticosteroids

• Injections– Corticosteroids,

hyaluronic acid, biologics• Braces

– Hinged, Offloader

Managing a Patient’s RiskWhen Is Surgery Right for You?

Minimize health factors that increase risk for potential problems after surgery

Health Considerations for a Knee Replacement

Risk Factors for a Knee Replacement

Risk Factors for a Knee Replacement (cont.)

13

Surgical Technique

Total knee technique

15

Total vs. Partial Knee Replacement

Total vs Partial Knee Replacement

Indications for Partial

Median Patient Age

Source:

19

Managing Recovery and Post-Operative Pain

Source:

A multi-disciplinary team convened by orthopedic surgeons, and included; anesthesiologists, pharmacists, Clinical Nurse Specialists, physical therapists, and bedside orthopedic RNs.

Goals:• Decrease post-operative pain,• reduce physician variation,• improve patient compliance with ambulation and exercises, • increase patient satisfaction, and• reduce patient falls.

The Palomar Health Pain Protocol

• Reduced need of Patient Controlled Analgesia

• Time patients spend in severe pain was dramatically reduced

• Commonly heard from our patients:

“I had surgery before and this is a totally different and

better experience!”

The Palomar Health Pain Protocol

Methods

• Preop meds• Intraop methods• Periop methods• Postop protocols

• Preop cocktail• Local anesthesia• Adductor canal block• Postop regimen that

minimizes use of narcotic/opioid meds

24

TKA Outcomes

Length of Stay

BMJ, 2018

Length of Stay2.3

2.1 2.0 1.9 1.8 1.8 1.6 1.5

-

0.5

1.0

1.5

2.0

2.5

PMC Escondido PMC Poway2015 2016 2017 2018

% of Patients Discharged on POD1

11%

31%28% 34%45% 49%

67%76%

0%

20%

40%

60%

80%

100%

PMC Escondido PMC Poway

2015 2016 2017 2018

Patient Falls per 1,000 Bed Days

-

1.68

0.70

1.68

0.94

1.81

3.18

3.94

-

1.00

2.00

3.00

4.00

5.00

PMC Escondido PMC Poway

30-day All-Cause Readmissions

1.1%2.6%

0.9% 1.3%1.6%0.3%

0.0%

2.5%

5.0%

7.5%

PMC Escondido PMC Poway2016 2017 2018

Published Benchmarks3.37% (National Average)2.69% (Top 10%)

Discharge Planning

Source:

Source:

Patient Reported Improvement in Function and Pain (KOOS Jr.)

Source:

What’s Next for Total Knee Arthroplasty

• Report back on 12-month functional outcomes (HOOS and KOOS) in August 2020

• Achieve zero avoidable readmissions and falls

• At-home recovery vs. Skilled Nursing• Decrease number of falls post

operatively